Phantom limb pain (PLP) can be a challenging and often debilitating condition following amputation. The
sensation of pain in a missing limb can significantly impact your quality of life. As physiotherapists, we understand
the complexities of PLP and are committed to providing effective pain management strategies. One such tool,
within the scope of physiotherapy practice, is Transcutaneous Electrical Nerve Stimulation (TENS). This guide
offers a detailed, step-by-step approach to using TENS effectively for PLP relief. Remember, TENS is most
effective as part of a comprehensive physiotherapy plan, not as a standalone treatment.
TENS units work by delivering mild electrical impulses through the skin via electrodes. These impulses stimulate
nerves, which can help to reduce pain signals and promote the release of endorphins, the body's natural
painkillers. This blog will explore how TENS can be a part of your pain management strategy, focusing on
proper usage and safety considerations.
PLP is a complex phenomenon, and researchers are still learning about its underlying mechanisms. It's thought
that changes in nerves at the amputation site and in the brain play a key role. TENS offers a non-pharmacological
approach to pain management by targeting these nerve pathways. Electrical stimulation actively disrupts the
transmission of pain signals. Furthermore, TENS can stimulate the release of endorphins, providing natural pain
relief.
Before starting TENS therapy, a thorough assessment by a physiotherapist is essential to evaluate your pain,
medical history, and overall health status. Physiotherapists often integrate TENS with other pain management
strategies, such as medication, exercise, and psychological support. Your physiotherapist can help you develop a
comprehensive treatment plan that addresses your individual needs. If you have a pacemaker or other implanted
medical device, if you are pregnant, or if you have certain skin conditions, TENS may not be suitable for you.
Always disclose your complete medical history to your healthcare provider before starting TENS therapy.
Proper preparation is key to ensuring the safety and effectiveness of TENS therapy. Here's a step-by-step guide
to help you get started:
• Consult with a Physiotherapist: This is the most crucial step. A physiotherapist can assess your condition,
determine if TENS is appropriate, and provide guidance on electrode placement, intensity settings, and treatment
duration.
• Understand Your TENS Unit: Familiarize yourself with the controls and features of your specific TENS unit.
Read the user manual carefully and understand how to adjust the intensity, frequency, and pulse duration. Check
the TENS unit for any damage before use.
• Prepare the Skin: Clean the skin where you will be placing the electrodes with soap and water. Ensure the
skin is dry before applying the electrodes. Shaving the area may be necessary if there is excessive hair.
• Gather Supplies: Have all necessary supplies readily available, including the TENS unit, electrodes, conduc-
tive gel (if required), and a mirror (if needed for electrode placement).
Proper electrode placement is critical for achieving optimal pain relief with TENS. The goal is to target the nerves
that are contributing to the phantom limb pain. Here are some common placement techniques, always under the
guidance of your physiotherapist:
• Around the Amputation Site: Placing electrodes around the residual limb can help to stimulate the nerves in
the area and reduce pain signals.
• Along Nerve Pathways: Your physiotherapist may recommend placing electrodes along the nerve pathways
that correspond to the missing limb. For example, if you have phantom pain in your foot after a below-knee
amputation, electrodes may be placed along the sciatic nerve. In one case, electrodes were positioned on the
posterolateral aspect of the residual limb along the distribution of the sciatic nerve.
This case highlights the potential benefits of targeting specific nerve pathways.
• Contralateral Stimulation: In some cases, placing electrodes on the corresponding area of the opposite, intact
limb can provide pain relief. This technique, known as contralateral stimulation, may help to balance nerve activity
and reduce pain perception. Two confirmatory cases have shown the effectiveness of contralateral stimulation.
• Acupuncture Points: Some physiotherapists trained in acupuncture may use acupuncture points to guide
electrode placement. These points are believed to be located along specific energy pathways in the body and
can be stimulated to relieve pain.
Important Note: Never place electrodes over broken skin, open wounds, or areas with impaired sensation.
Now that you've prepared for TENS therapy and understand the principles of electrode placement, here's a
step-by-step guide to using the TENS unit:
• Position the Electrodes: Following your physiotherapist's instructions, carefully position the electrodes on the
skin. Ensure that the electrodes are firmly attached and that there is good contact with the skin. In a study, the
electrodes were positioned on the posterolateral aspect of the residual limb along the distribution of the sciatic
nerve.
• Turn on the TENS Unit: Turn on the TENS unit and start with the lowest intensity setting.
• Adjust the Intensity: Gradually increase the intensity until you feel a comfortable tingling or buzzing sensation.
It's crucial to start with a low intensity and slowly increase it. Avoid settings that cause muscle contractions or
pain.
• Adjust the Frequency and Pulse Duration: Your physiotherapist will advise you on the appropriate frequency
and pulse duration settings for your specific condition. Experiment with different settings to find what works best
for you. High-frequency TENS (100 Hz) followed by low-frequency TENS (10 Hz) has been used effectively.
• Treatment Duration: The typical treatment duration is 20-30 minutes, but your physiotherapist may recommend
a different duration based on your needs.
• Monitor Your Pain Levels: Pay attention to your pain levels during and after the TENS treatment. Keep a
record of your pain levels and any changes you experience.
• Turn Off the TENS Unit: After the treatment, turn off the TENS unit and remove the electrodes.
Before starting TENS, it's beneficial to educate the patient about PLP and its underlying peripheral mechanisms.
The patient underwent high-frequency TENS (100 Hz) for 15 minutes, followed immediately by 15 minutes of
low-frequency TENS (10 Hz).
To maximize the effectiveness of TENS therapy for phantom limb pain, consider these additional physiotherapy
pain management strategies:
• Combine with Exercise: Regular exercise can help to improve circulation, reduce pain, and improve overall
function. Your physiotherapist can recommend specific exercises that are appropriate for your condition.
• Mindfulness and Relaxation Techniques: Stress and anxiety can exacerbate pain. Practicing mindfulness
and relaxation techniques, such as deep breathing exercises or meditation, can help to reduce stress and
improve pain management.
• Mirror Therapy: Mirror therapy involves using a mirror to create a visual illusion of the missing limb. This can
help to reduce pain and improve motor function.
• Desensitization Techniques: If you experience hypersensitivity in the residual limb, your physiotherapist may
recommend desensitization techniques, such as massage or tapping, to help reduce sensitivity.
While TENS is generally safe and effective, you may encounter some issues during treatment. Here are some
common problems and potential solutions:
No Sensation: If you don't feel any sensation when you turn on the TENS unit, check the following:
• Ensure the unit is turned on and the batteries are fresh.
• Make sure the electrodes are firmly attached to the skin
• Increase the intensity setting.
• Check the electrode wires for any damage.
Skin Irritation: If you experience skin irritation under the electrodes, try the following:
• Use hypoallergenic electrodes.• Clean the skin thoroughly before applying the electrodes.• Apply a thin layer
of conductive gel to the electrodes.• Change the electrode placement.
Pain Increase: If your pain increases during or after TENS treatment, reduce the intensity setting or discontinue
use. Consult with your physiotherapist to adjust your treatment plan.
TENS can be used as a long-term pain management strategy for phantom limb pain. However, it's important to
work closely with your physiotherapist to monitor your progress and adjust your treatment plan as needed.
Over time, you may find that you need to increase the intensity setting to achieve the same level of pain relief.
This is known as accommodation and is a normal phenomenon. Your physiotherapist can help you adjust your
treatment parameters to address accommodation.
Remember that TENS is just one component of a comprehensive pain management plan. It's important to con-
tinue with other therapies, such as exercise, mindfulness, and medication, as recommended by your healthcare
team. A systematic review of controlled clinical trials can provide further insights into the effectiveness of TENS.
TENS can be a valuable tool in managing phantom limb pain, offering a non-invasive and potentially effective
way to reduce pain and improve your quality of life. By following this step-by-step guide and working closely with
your physiotherapist, you can learn how to use TENS safely and effectively. Empowering patients, enhancing
outcomes, is our goal. If you are experiencing phantom limb pain, talk to your physiotherapist about whether
TENS is right for you. Share your experiences with TENS therapy or seek further information from a healthcare
provider to take control of your pain management journey.