Pain, 37 (1989) l-5

Ekvier

PAI 01385

Clinical Section

Effects of transcutaneous electrical nerve stimulation

on myofascial pain and trigger point sensitivity
Steven B. ~raff-~dford

*,**,

John L. Reeves

****,

Robert

L. Baker

* and Daryl Chiu

* Department ofAnesthesiology. Pain Management Center, UCLA School of Medicine, L.os Angeles, CA 90024 (U.S.A. j,
and * * UCLA Dental Research Institute, Los Angeles, CA 90024 (U.S.A.)
(Received 22 July 1987, revision received 27 September 1988, accepted 15 November 1988)

The effects of tr~scut~~us

S-=-Y

electrical nerve stimulation (TENS) on myofascial pain and trigger point sensitivity

were assessed. Four modes of TENS and a no-stimulation control were compared in a double-blind design. Stimulation, carried out
for 10 mm on 60 subjects (12/group), showed significant pain reductions with 100 Hz, 250 msec stimulation followed by 100 Hz, 50
msec and then pain suppressor TENS. No pain reductions were found in the 2 Hz, 250 msec TENS or the control. No significant
alteration in myofascial trigger point sensitivity, assessed with the pressure algometer, was found between the groups. The results
suggest that high frequency, high intensity TENS is effective in reducing myofascial pain, and that these pain reductions do not
refkct changes in local trigger point sensitivity.
Key wor&

TENS; Trigger point sensitivity; Myofascial pain; Pressure algometer

Introduction

Transcutaneous
electrical
nerve stimulation
(TENS) is often used to treat acute and chronic
pain conditions [5,6,10,15,22J. The mechanism of
action is not clearly understood and varies with
stimulation frequency, pulse width and intensity
[12,13]. The effect of TENS on pain may be

r This study was supported by NIH/NIDR

Grant No.
DE07618-01. Statistical analysis was supported by the UCLA
Office of Academic Computing.
Correspondence to: Steven B. Graff-Radford, Department
of Anesthesiology, Pam Management Center, UCLA School of
Medicine, Los Angeles, CA 90024, U.S.A.
0~3959/89/~3.50

through peripheral mechanisms [3,4,24], or central

effects, by increasing
circulating
endogenous
opiates 1181, or by modulating autonomic responses [1,9,17J.
Although TENS is not described as a specific
myofascial trigger point (TP) modality by Travel1
and Simons [23], it has been successfully used to
reduce pain when applied over TP locations
[10,15]. The stimulation parameters and the mechanisms responsible for the reductions in myofascial pain with TENS have not been studied,
In the present experiment we sought to investigate the relative efficacy of 4 TENS modalities [14,16] and a no-stimulation control condition
on myofascial pain and trigger point sensitivity. A
double-blind factorial design was employed. Pain

0 1989 Elsevier science Publishers B.V. (Biom~ic~

Division)

was measured
was measured

on the VAS 19) and TP sensitivity

using a pressure algometer [X,19].

Methods
Subjects
Sixty patients,
45 females and 15 males, referred to the UCLA Pain Management
Center for
diagnosis and management
of chronic pain, served
as subjects. For inclusion in the study subjects had
to have clinically
active TPs which reproduced
their pain complaint
when palpated. Average age
of the subjects was 43.33 years (range 20-84).
Pain complaints
were located in the thorax and
lumbar spine, and frontal, temporal and occipital
regions of the head. Muscles in which TPs were
located and to which the TENS was applied included the trapezius, 43% (n = 26), paraspinalis,
10% (n = 6). splenius capitis and rhomboid,
23%
(n = 14), temporalis, 7% (n = 4), levator scapulae,
5% (n = 3), and masseter,
sternocleidomastoid,
deltoid, pectoralis major and infraspinatus,
12%
(H = 7). No subject had any prior experience with
TENS.
Apparatus
The pressure algometer,
used to measure TP
sensitivity, is a pain threshold meter, model PTHAF2 described by Reeves et al. [l!?]. It is commercially available
through
Pain Diagnostics
and
Thermography
Corporation,
17 Wooley Lane East,
Great Neck, NY 11021, U.S.A. This instrument
is
a force gauge calibrated in kg/cm attached to a
plunger with a 1 cm round rubber tip on its end. It
is used to assess sensitivity by applying constantly
increasing
pressure, at a rate of 1 kg/cm2/sec,
over the TP until the subject first feels pressure
change to pain. This pain threshold, measured in
kg/cm2, represents a reliable and valid quantification of TP sensitivity [19] and has proven useful
in assessing pre- to post-treatment
changes in TP
sensitivity [8].
Visual analogue scales (VAS) were used to assess
subjective ratings of the subjects current primary
pain complaint.
Anchor words on the 100 mm
horizontal lines were no pain on the left side and
most intense pain imaginable on the right [20].

Jhe TENS units used were the Staodyn Maxima, produced by Staodynamics
Inc., Longmont,
CO 80502, U.S.A., and the Pain Suppressor Model
GL106A,
produced
by Pain Suppression
Labs.
Inc., Elmwood
Park. NJ, U.S.A. Self-adhesive
electrode pads (5 X 2.5 cm) were used with the
Staodynamics
unit and sponge electrodes,
provided with the Pain Suppressor unit, were used as
recommended.
Procedure
Subjects were instructed
that the study was a
double-blind
trial and that they would randomly
receive 1 of 5 conditions,
one which was not an
active mode. They were further instructed
about
the sensations that might be experienced
and any
possible side-effects,
such as skin rash and discomfort.
Subjects were tested individually
during 1 experimental
session, lasting approximately
30 min.
After the first experimenter
located and marked
an active myofascial TP with an X, the pre-treatment VAS pain intensity and pressure algometer
measure of TP sensitivity was recorded following
the procedures described by Reeves et al. 1191, and
Jaeger and Reeves [S]. The first experimenter
then
left the treatment room.
Subjects then received 1 of 5 treatment modalities which was applied by a second experimenter,
blind to the pain ratings and algometer
values.
The 5 conditions
were: TENS A (N = 121, rate 2
Hz, pulse width 250 psec, delivered in an asymmetrical rectangular
biphasic wave form (cathode
phase), with zero net DC current, and an intensity
set to the strongest tolerable sensation with muscular contraction
(appro~mately
lo-40
mA).
TENS B (N = 12), rate 100 Hz, pulse width 250
psec, delivered in an asymmetrical
rectangular
biphasic wave form (cathode phase), with zero net
DC current, and an intensity
set to the patients
comfort, below the threshold of muscular contraction (less than 39 mA). TENS C (N = 12), rate 100
Hz, pulse width 50 psec, delivered in an asymmetrical rectangular
biphasic
wave form (cathode
phase), with zero net DC current, and an intensity
set to the patients comfort, below the threshold of
muscular contraction
(less than 39 mA). TENS D,
also termed the Pain Suppressor
unit (N = 12),

offers a low output amperage (max 4 mA), and 15

msec bursts of high frequency pulses (120%20,000
Hz rectified to a monophasic
wave) with a burst
frequency of 15 Hz. The intensity
set at a level
just below that perceived by the subject at a low
amperage
of approximately
1-4 mA. TENS D
differs from most TENS units which have a higher
amperage, slower frequency and wider pulse width.
Control
condition
(N = 12), this group was divided into 2 groups, 6 received placement
of the
Staodynamics
unit, and the remaining 6 subjects,
the Pain Suppressor unit. The battery was not in
place in the control group TENS devices. TENS
lasted 10 min and the electrodes
were placed
bilaterally
at the same location, with the negative
electrode over the active TP.
Following
the 10 min treatment
period, the
second experimenter
removed the electrodes and
the first experimenter,
blind to the experimental
condition,
re-entered
the treatment
room and repeated the VAS and pressure algometer readings.
This constituted
the post-treatment
assessment.
Results
Split plot factorial analyses of variance with 5
levels of group (TENS A, TENS B, TENS C,
TENS D, control) as the between factor and 2
levels of trials (pre- and post-treatment
values) as
the repeated measures were used to analyze the
pre- to post-treatment
VAS pain intensity ratings
and algometer scores. The mean VAS and algometer scores are shown in Tables I and II, respectively.

VAS pain ratings

Split plot factorial ANOVA of the VAS ratings
showed a reliable trials main effect indicating
a
significant overall pre- to post-treatment
reduction
in pain (F (1, 45) = 30.59, P < 0.001) (mean pre
= 41.1 mm, post = 29.6 mm). In addition
the
group X trials interaction
was also significant
(F
(4, 45) = 4.77, P -cO.Ol),
suggesting
group differences in pre- to post-treatment
pain ratings. A
test of simple main effects showed that the only
reliable pre- to post-treatment
pain reductions
were found in the TENS B, TENS C and TENS D
conditions. No pre- to post-treatment
pain changes
were found in the TENS A and control conditions. The test of simple main effects also revealed
significant group differences in the pre-treatment
period reflecting a sampling bias in spite of the
random group assignment.
In order to control for
the significant pre-treatment
group differences in
VAS pain ratings, change scores were computed
by subtracting
pre- from post-treatment
VAS ratings for each subject. These change scores were
analyzed using a one-way ANOVA with 5 levels
of group (TENS A, TENS B, TENS C, TENS D,
control) as the between-group
factor. A highly
reliable group effect emerged (F (4, 45) = 4.77,
P < 0.001).
Tukeys multiple comparison
indicated
that TENS B had a significantly
greater pre- to
post-treatment
pain reduction
than the other
treatment conditions.
The TENS C and TENS D
had similar pain reductions and significantly
larger
than the TENS A and control conditions,
which
did not differ from each other. The change scores
are summarized
in Table I.

TABLE I
PRE-TREATMENT
(Pre) AND POST-TREATMENT
ANALOGUE
SCALE (VAS) FOR PAIN

(Post) MEANS AND STANDARD

TENS modalities listed in order of significant reduction in

pain.

TENS mode

Post

TENS B
TENS C
TENS D
TENS A
Control

Pre

DEVIATIONS

FOR THE VISUAL

Difference

Mean

(S.D.)

Mean

(SD.)

Mean

(SD.)

57.2
45.1
33.8
34.3
34.8

(22.10)
(19.38)
(25.58)
(33.70)
(22.94)

28.3
31.8
24.1
33.7
30.2

(18.06)
(21.37)
(24.07)
(29.02)
(15.92)

28.9
13.3
9.7
2.4
4.6

(17.16)
(19.49)
(9.76)
(13.94)
(13.34)

4
TABLE

!I

PRE-TREATMENT
(Pre) AND POST-TREATMENT
(Post) MEANS
TER SCORES (kg/cml)
OF TRIGGER
POINT SENSITIVITY
TENS mode

TENS
TENS
TENS
TENS
Control

B
C
D
A

Pre

~..

Mean

(S.D.)

1-J
_
_,

f1.W

2.x
3.9
2.4
3.2

(1.56)
(1.67)
(0.96)
(1.09)

AND

STANDARD

DF.V1AII<)NS FOR THE ALGOMIi

Post
_____
Mean

(S.D-,

Difference
-Mean

(SD.)

4.9
3.5
4.4
3.1
3.9

(1.77)
(1.32)
(1.87)
(1.41)
(1.35)

1.19
0.6X
0.46
0.66
0.83

(1.41)
(0.93)
(1.10)
(0.65)
(1.02)

The split plot ANOVA for the algometer scores

showed highly reliable trial main effect indicating
pre- to post-treatment changes in algometer values
(F (1, 45) = 26.16, P < 0.001). The mean algometer scores were pre = 3.24 kg/cm2 and post = 4.01
kg/cm2 and reflected a decrease in TP sensitivity.
The group main effect and group X trial interaction failed to achieve significance. In addition,
no group differences were found when analyzing
the pre- to post-treatment algometer change scores.
The decreases in TP sensitivity probably reflect a
habituation to repeated algometer measurements,
as the experimental conditions failed to differ
from the control condition. The mean and standard deviations for pre- and post-treatment algometer scores are shown in Table II.

Discussion

This study demonstrated the relative effects of

4 modes of TENS on myofascial pain and TP
sensitivity. A 10 min application of TENS B resulted in a 50% reduction followed by a 30% pain
reduction with TENS C and TENS D. No significant pain reductions were found in either the
TENS A or control conditions. While significant
pre- to post-differences in TP sensitivity were
found, they were not a result of the treatment
conditions and likely reflected habituation to the
me~urement procedure since the control group
showed the second greatest changes in TP sensitivity. However, it is possible that with a larger

._-_-_._-. I.
-------

sample size the TENS B condition may have shown

a significant change in trigger point sensitivity.
The superior analgesic effect of TENS B may
relate to the parameters of intensity which include
amplitude, pulse width and frequency 12.161.TENS
B was assumed to be the highest intensity stimulation, due to the high rate, long width, and high
amplitude. TENS C utilized high rate (100 Hr.),
but pulse width was short and ampIitude was
moderate. This was less intense when compared
with TENS B. TENS D, the Pain Suppressor unit,
used a minimal amplitude, short pulse width
stimulation and the frequency was much lower (15
Hz). It is possible that the greater intensity, defined by combinations of amplitude pulse width
and frequency, recruited more afferent pain inhibiting nerve fibers [2,7,12,16] and, therefore,
maximized the pain relief through central inhibition [13,15].
Pain relief associated with low frequency stimulation similar to that delivered in TENS A, but
with small bursts of stimuli rather than single
pulses as described in TENS A, is thought to be
endorphin mediated 1211. A stimulation time in
excess of 20 min is usually suggested for its action.
Despite the use of moderate amplitude and long
pulse width, the TENS A stimulus parameter and
the short 10 min application may not be sufficient
to initiate an endorphin response, or may not have
been sufficient to activate the afferent nerve fibers
required for pain inhibition. Further evaluation of
TENS A stimulation for longer periods and its
response to naloxone would better determine its
mode of action.

Myofascial pain is typically treated by interventions aimed at altering TP sensitivity [8,23]. This
study demonstrates
that TENS can produce reduction in myofascial pain without altering local
TP sensitivity,
perhaps through a central inhibitory mechanism.
These results also suggest that
TENS alone may be insufficient
for the long-term
treatment of myofascial pain, since TP sensitivity
appears to remain unaltered.
Perhaps the pain-reducing properties of TENS coupled with stretching would produce the desired effect of reducing
pain and TP sensitivity
as previously
demonstrated with fluorimethane
spray and stretch [8].
Further studies are required to determine the significance of these results in terms of clinical therapy and central
and peripheral
mechanisms
mediating myofascial pain.

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