Research Report

Blood Flow Changes in the Trapezius

Muscle and Overlying Skin Following
Transcutaneous Electrical Nerve
Stimulation
Margareta LSandberg, Matilda K Sandberg, Johanna Dahl
ML Sandberg, PT, PhD, is Re-
searcher and Lecturer, Depart-
Background and Purpose ment of Rehabilitation Medicine,
Various researchers have studied the effects of transcutaneous electrical nerve stim- Faculty of Health Sciences, and
ulation (TENS) on hemodynamics. The purpose of tliis study was to examine the Pain and Rehabilitation Centre,
effects of TENS on local blood flow in the trapezius muscle and overlying skin. University Hospital, S-581 85
Linkoping, Sweden. Address all
correspondence to Dr Sandberg
Subjects at: margareta.sandberg!io.se.
Thirty-three women who were healthy, aged 25 to 55 years, were randomly assigned MK Sandberg and | Dahl were stu-
to receive 1 of 3 different modes of TENS. dents in the Physiotherapy Pro-
gram, Faculty of Health Sciences,
Methods Linkoping University, Linkoping,
Sweden, at the time of this study.
Skin and muscle hlood flow were monitored noninvasively using a new application
of photoplethysmogmphy for 15 minutes of TENS applied at iiigh frequency (80 Hz) [Sandberg ML, Sandberg MK,
Dahl ). Blood flow changes in the
and sensory-level intensity' and at low frequency (2 Hz) and motor-level intensity- and
trapezius muscle and overlying
for 15 minutes after stimulation. Subliminal 80-Hz TENS was used as a control. Blood skin following transcutaneous
flow was monitored simultaneously on stimulated and nonstimulated shoulders. electrical nerve stimulation. Phys
Ther. 2007-87A 047-]05S.]
Results 2007 American Physical Therapy
Blood flow in the trapezius muscle, hut not skin blood flow, increased significantly Association
with motor-level 2-Hz TENS, whereas no increase occurred with sensory-levci 8()-Hz
TENS or subliminal 8()-Hz TENS.

Discussion and Conclusion

Muscle contractions induced by motor-level 2-Hz TENS appear to be a prerequisite for
increasing blood flow in the trapezius muscle. However, high stimulation intensity
may prevent increased blood flow in the overlying skin.

Post a Rapid Response or

find The Bottom Line:
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August 2007 Volume 87 Number 8 Physical Therapy 1047

Blood Flow Changes Following TENS
U
.seci since the 1970s for pain
inhibition in acute as well as
chronic pain states, trans-
ctitancous electrical nerve stimula-
tion (TENS) stimulates primary affer-
ents by low-voltage controlled
electrical pulses through electrodes
applied to the skin.' A number of
physiological studies have suggested
that afferent activity- induced by
TENS inhibits nociceptive transmis-
sion in the spinal cord through pre-
synaptic and postsynaptic inhibit()r>'
mechanisms.- In addition lo studies
on pain relief, the effect of TENS on
blood flow has been itwestigated in
a number of studies.*" Segmental
inhibition of s)nipathetic vasocon-
striction, release of vasodilator pep-
tides from sensory neurons, and the
muscle pump action of contracting
muscles all have been suggested as
probable mechanisms in increasing
hlood blow following TENS. How-
ever, the results are not consistent;
for example, some studies detected
an increase in hlood flow, and other
studies detected no effect.
In a study hy Wikstrom et al,* skin
blood flow in participants who were
healthy was increased with TENS of
low freqtiency (2 Hz) but not with
TENS of high frequency (100 Hz),
whereas in another study,' skin
hlood flow in ischemic tissue was
found to increase with TENS of 80
Hz, eliciting a strong tingling sensa-
tion. Low-frequency TENS (2 Hz) of
the highest tolerable intensity, but
not by low-intensity stimulation, in-
creased microcirculution in patients
with chronic leg ulcers.^ However,
in the tissue surrounding the ulcers,
the blood flow increase was substan-
tially less. Moreover, low-frequency
TENS (4 Hz), hut not high-frequency
TENS (110 Hz), applied over the me-
dian nerve in suhjects who were
healthy resulted in increased skin
blood flow, provided thai the stimu-
lation intensity was ahove the motor
threshold level/'" 'ITie different re-
sults of these studies probably reflect
1048 Physical Therapy Volume 87
differences in stimulation parame-
ters and in stimulation and recording
sites, the circulatory status of the tis-
sue, and different properties of the
measuring techniques. Studies of
TENS frequently use laser Doppler
flowmetr\' (LDF)*^ and venous occlu-
sion plethysmography'^ to measure
hlood flow changes in skin and vol-
ume changes in a limh segment,
respectively.
The effect of TENS on local muscle
hlood flow has not been investigated
previotisly. This may he the case be-
cause an appropriate measurement
techniqtie has not heen availahle. Al-
though further developments of the
LDF techniqtie allow blood perfu-
sion to he measured invasively in lo-
cal muscle tissue,'" one drawhack of
the method is the trauma caused by
the insertion of the optic fiber,
which affects the hlood flow. Thus,
the invasive LDF technique is not a
suitahle teehnique when investigat-
ing local effects of TENS on muscle
hlood flow. Changes in muscle blood
flow may be estimated indirectly by
measuring total blood flow in a limb
segment tising techniques such as
venous occlusion plethysmography.''
Using this technique, burst-mode
TENS (burst frequency of 20 and 2
Hz, respectively) with an intensity-
high enough to cause muscle con-
tractions has been shown to increase
calf blood flow." '2
Photoplethysmography (PPG) is an
established optical technique for
ctintiniious skin blood flow monitor-
ing.'"-* In PPG, light from a light-
emitting diode (lED) is directed to-
ward the skin and is absorbed and
scattered in the tissue. A small
amount of this light is received hy a
photodetector placed adjacent to the
LED (reflection mode). Variations in
the photodetector signal are related
to changes in blood flow and blood
volume in the underlying tissue.
With the use of custom-designed op-
tical prohes with accompanying PPG
Number 8
instrumentation, PPG recently has
heen used for noninvasive continti-
ous measurements of blood flow
changes in the tibialis muscle'^"'
and the irapezius muscle'"" following
needle stimulation (acupuncture).
Noninvasive measuring methods
have large advantages over invasive
methods because they do not inter-
fere with the local blood flows under
study.
The purpose of the present study
was to investigate the effects of
TENS on blood flow in the trapezius
muscle and overlying skin in women
who were healthy using a new non-
invasive application of PPG. Because
otir main interest was directed to-
ward effects on muscle blood flow,
we chose to use TENS of high inten-
sity, hut helow the limit of discom-
fort, as determined individually hy
the suhjects. We also chose (o use
TENS of hoth low and high fre-
quency, although our hypothesis
was that low-frequency TENS would
be the most effective mode.
Method
Subjects
Thirty-three women who were
healthy were recruited from stu-
dents and staff at the University Hos-
pital in Linkoping, Sweden. Inclu-
sion criteria were age hetween 25
and 55 years, nonsmoking, and
Swedish speaking. Exclusion criteria
were neck and slioulder pain wilhin
the last 3 months, pregnancy, breast-
feeding, alcohol or drug abuse, and
any disease or medication with po-
tential effects on circulation. The
suhjects were instructed not to cat,
not to drink caffeine-containing
drinks, and not to exercise within 2
hours hefore the se.ssions. All suh-
jects were informed verbally and in
writing about the study, and they
gave their informed written consent.
Blood Flow Recording
A new application of P1*G (currently
under development and not yet com-
August 2007
 Blood Flow Changes Following TENS

mercially available'") was used in the

present study to monitor hlood tlow
changes simultaneotisly in the trape-
zius muscle and overlying skin. The
custom-designed PPG probes (48 X
40 mm) for the trapezius muscle con-
sisted of 4 photodetectors, 4 green
(560-nm) LEDs, and 2 near-infrared
(804-nm) LEDs placed in a special
pattern and embedded in black-
colored silicon (Fig. 1). The center-
to-center distance between the LEDs
and the photodetectors was 3-5 mm
and 25 mm for wavelengths of 560
and 804 nm, respectively, llie
40 mm
560-nm LED monitored the superfi-
cial blood flow, and the 8()4-nm LED
monitored the deeper hlood flow
(preferentially the muscle flow). The
LED at 804 nm ensures that the
blood flow signal will not he affected PPG
hy variations in oxygen saturation. instrument
LED (green)
There is no gold standard for measur-
ing local muscle hlood perfusion. Photodetector
Therefore, evaluation of the new ap- Laptop
plication of PPG was hased on assess- LED (near-infrared)
ments of changes in blood flow to Figure 1.
various provocations known to af- The experimental setup, including probe application site and instrumentation, and
fect blood flow.'** These provoca- detaiis of the optical components and physical dimensions. The transcutaneous nerve
tions included post-exercise hyper- electrical stimulation electrodes (not shown) were applied on either side of the probe.
emia and hyperemia following the PPG ^photoplethysmography, LED=light-emitting diode.
application of liniment. The experi-
ments clearly showed this method's
ability to discriminate hetween
mined by Doppler tiltrasound. The Transcutaneous Electrical
blood perfusion at different depths.
results showed that the light pene- Stimulation
In addition, simultaneous measure-
trated down to a depth of 13.6 mm A pocket-sized, 2-channel stimulator
ments using Doppler ultrasound and
from the skin surface.'** The mean (CEFAR Primo model-O was used
the new PPG application were per-
distance between the skin surface for the electrical stimulation. The
formed to demonstrate different
and the fascia of the trapezius mus- TENS unit delivered constant asym-
properties of these devices. During
cle was 5.8 mm (SD=1.7) in 15 fe- metrical biphasic balanced square-
the evaluation of the prohe in the
male patients with fihromyalgia'^ wave pulses of high frequency (80
study by Sandherg et al,'" an optical
and 4.9 mm (SD=1.3) in 29 female Hz) and low frequency (2-H/ burst
fiber was inserted into the trapezius
subjects who were healthy (ML Sand- mode, 8 puises per burst) with a
muscle underneath the probe in 14
herg and LG Lindherg, unpuhlished pulse duration of 180 microseconds.
suhjects who were healthy and con-
data, 2004). This experiment en- Motor-level 2-Hz TENS was intended
nected to an optical power meter for
sured that the light penetrated down to elicit strong, but not painful or
recording and confirming that the
to the muscle tissue, enabling mus- unpleasant, contractions of the
light reached the muscle tissue. The
cle blood flow measurements. shotilder muscles, and sensorv' level
location of the liher tip was deter-
80-Hz TENS was intended to elicit
strong sensations of paresthesia, but
* Department of Biomtdital Enjiineering,
Linkoping University, S-581 85 Linkoping, * CEFAR Medical AB, lUeon ScitncePark.
Sweden. Scheelevagen 19A, SE-22.^ 70 Lund, Sweden.

August 2007 Volume 87 Number 8 Physical Therapy 1049

Blood Flow Changes Following TENS
not muscle contractions. Subliminal
80-Hz TENS with the lowest possible
current intensity (0.5 mA), resulting
in no sensation at all, was used as a
control. Two 40- X 60-mm elec-
trodes^ were used.
Procedure
The subjects were randomly as-
signed, in equal numbers, to one of
the three IS-minute TENS inter\'en-
tions (sensory-level 80-Hz TENS,
motor-level 2-Hz TENS, or subliminal
TENS) by the use of opaque sealed
envelopes. The trial was conducted
in a quiet room with moderate light
and a temperature between 23" and
25C. The subjects sat with bare up-
per body in an armchair with their
back supported up to the lower part
of the scapulae and with their arms
resting on a cushion on their knees.
The)' were instructed to sit relaxed
and not to talk during the blood flow
recordings. 1 he FPCi probes were at-
tached with adhesive tape to the
most prominent part ofthe trapezius
muscles of the right and left shotil-
ders. If necessary, the prohes were
moved slightly in order to detect sig-
nals. Two electrodes then were at-
tached to the skin on either side of
the PPG prohe on the dominant
shoulder. With the motor-level 2-Hz
TENS, the cathode was placed over
the medial part of the trapezius mus-
cle. With the sensory-level 80-Hz
TENS and subliminal TENS, tbe cath-
ode was placed over the lateral part
of the muscle.
Sensory and motor thresholds were
noted for each subject. The sensory
threshold was determined and quan-
tified by tbe current intensity (in
milliamperes) tbat elicited the first
sensation of the stimulation. The
motor threshold was determined
and quantified hy the current inten-
sity of motor-level 2-Hz TENS that
elicited the first sensation of contrac-
tion of the muscle. The subjects
were informed that the stimulation
during the trial would elicit a strong,
1050 PhysicalTherapy Volume 87
but not painful, sensation of pares-
thesia with sensory-level 8()-Hz
TENS, visible muscle contractions
with motor-level 2-Hz TENS, and no
sensation with subliminal TENS.
They also were infonned that the
stimulation intensity would be in-
creased, it' necessarj', in order to
maintain the initial sensation.
The investigation started after at
least 20 minutes of acclimatization.
The different types of TENS interven-
tions lasted 1S minutes. The current
intensity with sensory- and motor-
level TENS was increased quickly un-
til the subject felt minor discomfort
and then was immediately decreased
below this limit, as determined indi-
vidually by the subjects. Immediately
after the trial, the subjects rated the
pain or discomfort that they experi-
enced during the trial using a visual
analog scale (VAS).
Bloi)d flow was recorded for 60 sec-
onds before the intervention and
then intermittently for 60 seconds
ever}' 3 minutes during tlie 15-
minute stimulation and for another
15 minutes after stimulation. During
the last 20 seconds of the recordings
during stimulation, the current was
abruptly switched off to allow for
clear PPG signals for analyses and
then quickly switched on again. The
signals were processed in an ampli-
ticr and stored on a personal
computer.
Data Analysis
Blood flow changes, based on the
last 20 seconds of the 6()-second re-
cordings, were expressed as a per-
centage of the resting (baseline)
value (denoted as 0). Mean values of
stimulation and poststimuiation peri-
ods were calculated and used for
nonparametric analyses using the
Statview 5.1 statistical package.* The
Kniskal-Wallis test was used to test
^ SAS Institute Inc, PO Box 8000. Cary. NC
27511.
Number 8
for differences between groups. Tbe
Mann-Whitney U test was used for
pair-wise comparisons of significant
findings. The Wilcoxon matched-
pairs signed-ranks test was applied
for pair-wise comparisons within
groups and to test for differences be-
tween the stimulated and nonstimu-
lated shoulders. A P value of <.O5
(twotailed) was considered signifi-
cant. Eigures 2 and 3 show the
means and standard errors of the
mean.
Results
All subjects completed the study.
However, data for 5 subjects were
excluded from the analyses due to
difficulties in analyzing the PPG sig-
nals in 2 subjects, a missing baseline
value in 2 subjects, and I subject
being pregnant. Tlie 28 subjects
whose data were included in die fi-
nal analyses had a mean age of 37.0
years (SD=7.8). The age distribution
was uneven in the sense that more
subjects were below than over the
age of 40 years (Table). The stimula-
tion intensity (initial stimulation
intensity and adjusted stimulation
intensity, respectively) was between
I.Z and 2.4 times the sensor)- thresh-
old (220%-240% of sensory thresh-
old) with sensor\'-level 8()-Hz lENS
and 0.2 times the sensor) threshold
(20% of sensory threshold) with sub-
liminal TENS. With motor-level 2-Hz
TENS, the intensity was 2.6 to .3.3
times the sensory threshold (260%-
330% of sensory threshold), or 1.8 to
2.3 times the motor threshold
(180%-230% of motor threshold).
Muscle Blood Flow -
Eigure 2A shows the relative muscle
blood flow changes throughout the
study period for the 3 TENS groups.
The patterns of blood flow change
differed substantially among groups.
Blood ilow rose rapidly with the
onset of motor-level 2-Hz TENS;
after cessation of the stimulation, it
quickly approached the baseline
level. In contrast, the modest blood
August 2007
 Blood Flow Changes Following TENS

flow increase with subliminal TENS Muscle Blood Flow

was not related to tbe onset of stim-
250-
ulation, but rather showed a slowly
increasing pattern throtighout the
^ 200-
study period.
^ 150-
A significant difference existed
c
among the TENS interventions (Z

(P<.0001) in that the mean muscle

blood flow increase was significantly ^ 100'
larger with motor-level 2-Hz TENS
compared with both sensory-level I 50'
8O-H2 TENS iP= .001) and subliminal
TENS (P=.OOI). No difference was 0'
found between sensory-level 80-Hz -50 0 3 6 9 12 15 18 21 24 27 30
TENS and subliminal TENS. During Minutes
the 15-minute post-stimulation pe-
riod, no significant difference in B 250-1 Skin Blood Flow
mean blood flow increase was found
between motor-level 2-Hz TENS and 200-
subliminal TENS, both of which
were superior to sensorj'-ievel 80-Hz
TENS (/'=.OO4 and P=.O34. respec-
tively). Blood flow increase was sig- 100-
nificantly greater with motor-level
2-Hz TENS than with subliminal i SO
TENS until 3 minutes post- Q:

stimulation (P=.O28). 0-

To control for a potential warming -50

effect of the measuring device on
blood flow, simultaneous measure-
ments were performed on the non-
stimulated shoulder. No differences
in mean blood Ilow increase existed
among the TENS interventions in the
nonstimulated shoulder, either dur-
ing the lS-minute stimulation period
or the 15-minute post-stimulation pe-
riod (Fig. 3A). Only with motor-level
2-Hz TENS did a significantly larger
mean blood flow increase exist in
the stimulated shoulder than in the
nonstimulated shoulder both during
stimulation CP= .008) and after cessa-
tion of stimulation (P=.O13). Signifi-
cant increases in muscle blood flow
during and after stimulation com-
pared with baseline existed in the
nonstimulated shoulder only with
subliminal TENS ^ = . 0 1 1 and
P=.OO8, respectively); however,
these changes were not significantly
0 3 6 9 12 15 18 21 24 27 30
Minutes
Figure 2.
Line graphs depicting relative changes (expressed as a percentage) in (A) muscle blood
flow and (B) skin blood flow with sensory-level 80-Hz transcutaneous electrical nerve
stimulation (TENS) (HI), motor-level 2-Hz TENS (LO), and subliminal 80-Hz TENS (Sub)
throughout the study in 28 v\/omen v^ho were healthy. The blood flow values are
expressed as the mean ( 1 SEM). The straight horizontal line indicates 15 minutes of
TENS.
different from those in the stimu- during stimulation (P=.OO8); how-
lated shoulder (Pig. 3A). ever, this increase w^as not signifi-
cantly different from the increase in
Skin Blood Flow the nonstinuilaled shouider
Relative changes in skin blood flow (Fig. 3B). During the post-stimulation
for the 3 TENS groups throughout period, an increase existed in mean
the study period are shown in Eigure blood flow with motor-level 2-Hz
2B. No significant differences existed TENS iP=.02S) and subliminal TENS
among the TENS interventions dur- (/*=.()11); however, this increase
ing or after cessation of TENS in ei- was not significantly different from
ther the stimulated shoulder or the that in the nonstimulated shoulder
nonstimiilated shoulder (Tig. 3B). (Fig. 3B).
Only with subliminal TENS was an
increase found in mean blood flow

August 2007 Volume 87 Number 8 PhysicalTherapy 1051

Blood Flow Changes Following TENS

Muscle Blood Flow During TENS B Skin Blood Flow During TENS
225- 225-
200- 200
g 175-
I 150i
Ml
E 175
at
150
HI

D LO LO
u
0, 125 1
Sub 5 125
<u
Sub

"5 100- s 100

J2
75- K 75

50-

Stimulated Shoulder Nonstimulated Shoulder Stimulated Shoulder Nonstimulated Shoulder

225 Muscle Blood Flow After TENS Skin Blood Flow After TENS
200
175
HI

U 125 D LO

I 100 Sub

^ 75
SO

25
0

Stimulated Shoulder Nonstimulated Shoulder Stimulated Shoulder Nonstimulated Shoulder

Figure 3.
Bar graphs depicting relative changes (mean of all measurements) in (A) muscle blood flow and (B) skin blood flow in stimulated and
nonstimulated shoulders, respectively, with sensory-level 80-Hz transcutaneous electrical nerve stimulation (TENS) (HI), motor-level
2-Hz TENS (LO), and subliminal 80-Hz TENS (Sub) in 28 women who were healthy. The graphs are separated according to changes
during the 15-minute application of TENS (top) and during the 15-minute post-stimulation period (bottom).

Table. Discussion
Age Distribution of Subjects Randomly Assigned to Different Croups of The prinini")' results (if this stticly
Transcutaneous Electrical Nerve Stimulation (TENS) were thai the trapeziu-s muscle blood
Age Motor-Level Sensory-Level Subliminal Total flow in women who were healthy
(y) 2-Hz TENS 80 Hz TENS 80-Hz TENS increased sifjnificantly with motor-
3 3 II t)
level 2-Hz ri-NS, which produced
visible muscle contractions, whereas
30-.Vt 1 1 3 S
no increase existed with sensor)'-
3S-.3y 2 1 3 6 Itvel 8()-Hz TENS, which elicited a
40-44 2 3 2 7 strong sensation of paresthesia but
45-49 1 0 1 _> no muscle contractions, or with sub-
liminal TENS. As was evident when
50-SS 1 1 0 2
comparing stimulated and nonstimu-
r.ital 1(1 9 is lated shoulders, skin blood tlow
overlying the trape/ius muscle did
not increase following any of the
TENS interventions.

1052 Physical Therapy Volume 87 Number 8 August 2007


Methodological Considerations
Different ckctrical stimulation
parameters between and within
groups were used in the study. First,
the placement of cathode and anode
wa.s reversed with motor-level 2-Hz
TENS and sensory-level 80-Hz TENS.
In order to facilitate muscle con-
tractions witli motor-level 2-Hz TENS,
the cathtxie was i>laced over the
most prominent part of the muscle
belly, medial to the PKi probe. With
sensory-le\el 8(VHz 7T.NS, the cathode
was placed lateral to the probe to min-
imize the risk of pmdiicing muscle
contrdctiDns. Second, 2 different fre-
quencies were used: 2 Hz (mot(jr-level
TENS) and 80 Hz (sensory-level ITNS).
Motor-level 2-Hz TENS was intended
to produce visible muscle contrac-
tions, and sensor>'-level 8(>-Hz lENS
was used to elicit a strong, but not
painful, sensation of paresthesia.
Third, the intensity of stimulation
differed between the groups, with
motor-level 2-Hz TENS having a
higher intensity and sensory-level
80-Hz TENS having a lower stimula-
tion intensit>\ Fourth, the intensity
of the stimulation was not fixed, but
differed among the subjects during
the lS-minute stimulation period. In
order to prcKluce coiitinuousl)' strong,
but not painful, muscle contractions
and paresthesia, respectively, through-
out the l>minute TENS intervention,
'A fixed stimulation intensity' could
not l>e used, but had to be individ-
ually adjusted. Thus, the rationale for
using diftcrent electrical stimulation
parameters was based on the purpose
of each t\'pe of stimulation (ie, to pn>
duce and maintain a similar level of
muscle contractions and paresthesia,
respectively).
To our knowledge, noninvasive real-
time measurement of local muscle
blood flow following TENS has not
been performed previously. Venous
occlusion plethysmography'' has
been used to examine heniod) namic
effects of TENS; however, this exam-
August 2007
Blood Flow Changes Following TENS
ination showed only increased calf
blood tlow following electrical stim-
ulation above the motor thresh-
old." '^ This technique is based on
determining total volume increase
versus time in an entire limb seg-
ment when venous outflow is ar-
rested and does not allow skin and
muscle blood flow to be measured
separately. Because different mea-
surement techniques have been used
in studies on hemodynamic effects
of TENS, results are not fully compa-
rable. Furtberniore, different mea-
surement techniques rely on differ-
ent teclinical principles and measure
different vascular beds.
One drawback of tbe PPCi probe in
long-term monitoring is a warming
effect from the light sources, leading
to a local temperature increase and
local blood flow regulation.'" U has
been sbown that the warming effect
from the probe during long-term
monitoring induces an increase of up
to 20% in the trapezius muscle blood
flow and overlying skin.'^ This level
of blood flow increase corresponds
approxittiately to the muscle blood
flow increase with subliminal TENS
in the present .study, thus rendering
subliminal TENS a suitable and valid
control in this respect.
As for skin blood flow, tbe use of
subliminal TENS as a control miglit
be uncertain because skin blood
flow increase following cessation of
stimulation was slightly more than
the 20% mentioned above.'^ How-
ever, the increase in blood flow with
subliminal TENS was not signifi-
cantly different from the skin blood
flow increase in the contnilatend,
nonstimuiated shoulder. In addition,
it was not until tbe end of the stim-
ulation period that the increase was
apparent. It also should be empha-
sized that the TENS electrodes them-
selves may inhibit convection,
thereby giving rise to increased skin
temperature and a subsequent rise in
skin blood flow due to temperature
Volume 87
regulation effects in the stimulated
shoulder.''^
A possible limitation ot tbe siudy
may be the relative short stimulatioa
time of IS minutes; however, this
period of stimulation also has been
chosen in other studies.*'" An appar-
ent limitation was that the PPG tech-
nique did not permit measurements
during tbe dynamic muscle contrac-
tions. Tbis limitation is similar to that
of other measurement techniques,
such as Doppler flowmetry. Thus, in
the present study, TENS was inter-
rupted for 20 seconds every 3 min-
utes for measurements. This means
that the effect of motor-level 2-Hz
TENS, which turned out to be the
mode of stimulation of interest,
couid be assessed only as immediate
post-exercise hyperemia, not as a re-
sult of ongoing contractions induced
by TENS.
Tbe subjects were told that the stim-
ulation would be strong, but not un-
comfortable or painful. During the
stimulation, the subjects were re-
peatedly asked to report whether the
intensity decreased; if this was the
case, tbe intensity was increased
again in order to maintain tbe initial
.sensation. Tbis procedure may bave
encouraged tbe subjects to accept an
intensity tbat was more intense than
intended because, after the end of
the study, some of the participants
reported either slight discomfort or
pain from the stimulation,
One benefit of tbe study was the use
of bilateral measurements. Because a
warming effect of tbe PPG probe is
known from previous studies,*^"'^
blood flow measurements were per-
formed bilaterally, although tbe elec-
trical stimulation was applied only
unilaterally. Few studies use bilateral
measurements to control for effects
on blood flow induced by the mea-
.siirement device itself.
Number 8 Physical Therapy 1053
Blood Flow Changes Following TENS
Muscle Blood Flow Changes
Post-exercise hyperemia is a well-
known plienomenon after both
static and dynamic contractions.-" It
is generally believed that exercise
liypcremia is a local phenomenon in-
cluding myogenic, metabolic, and
endothelium-mediated control.-*'
The muscle pump" accumulation of
local metabolic vasodilator sub-
stances and flow-induced vasodila-
tion produced by local release of re-
laxing factors derived from tbe
endotlielium were suggested as po-
tential mechanisms for the observed
vasodilation in the study by Sherr>' et
aV' following burst-mode TENS 25%
above motor threshold.
Although muscle blood flow in-
creased signiticantly with subliminal
TENS, this effect was not caused by
the stimulation itself but rather was
induced by the warming effect of the
PPG probe.'^ This conclusion can
readily be drawn by the finding of an
equal level of blood flow increase in
the contralaterai trapezius muscle. In
addition, blood flow with subliminal
TENS tended to increase not until
the end of stimulation, further point-
ing to a temperature regulation ef-
fect (Figs. 2B and 3B). A correspond-
ing warming effect on blood flow
was not observed with sensor\'-level
80-Hz TENS. Some subjects reported
unpleasantness or slight pain from
the stimulation, and possibly the
warming effect was overridden by
increased sympathetic tone and \a-
soconstdction as a result of tlic liigh
stimulation ititensity.
Using occlusion plethysmography. a
transient and similar level of increase
in calf blood flow following both vol-
untary contractions and burst-mode
TENS (20 and 2 Hz, respectively) was
observed when the intensit>' was
12S% of the motor threshold."'-
Similar to the present study, blood
flow returned quickly to the ba.seline
after cessation of stimulation. How-
ever, Miller et a l " showed that the
1054 PhysicalTherapy Volume 87
electrically induced muscle contrac-
tions produced a vasodilatation of a
slightly longer duration compared
with the voluntar>- contractions. In
another study,-- the effects on limb
blood flow in subjects who were
healthy with 110-Hz TENS applied
for 20 minutes over the peripheral
nerves were investigated using ve-
nous occlusion plethysmography.
The results showed that neither
sensor)- nor motor-level TENS influ-
enced calf blood flow. Although
these studies used other parameters
than in the present study, a trend
toward the same conclusion seems
reasonable: motor-level TENS elicil-
ing strong rhythmic muscle contrac-
tion, but not sensorj-Ievel TENS, en-
hances circulator)' effects of human
muscle.
Compared with the present results
on muscle blood flow, those induced
by needle stimulation (acupuncture)
in previous studie.s''*'" were of con-
siderably longer duration. Tliis find-
ing may reflect different underlying
mechanisms on blood flow induced
by TENS and acupuncture.
Skin Blood Flow Changes
Studies on blood flow changes fol-
lowing TENS bave dealt almost ex-
clusively with skin blood flow mea-
sured mostly by LDF." Inconsistent
results have been found depending
on different parameters of stimula-
tion (eg, intensity, frequency, site
and duration of stimulation) as well
as differences in recortling sites and
recording methods. Although hoth
LDF and PPCJ are used to measure
skin blood flow, results are not com-
parable because these modalities
monitor different depths of vascular
beds; LDF -1/2-I mm and PPG -1-2
mm.'" Several authors^'-"'-2-' have re-
ported an increase of skin blood flow
following low-frequency TENS.
Cramp et al" found that 15 minutes
of low-frequenc-y TENS (4 Hz) re-
sulted in significantly larger in-
creases in local skin blood flow com-
Number 8
pared with high-frequency TENS
(110 Hz) using strong but comfort-
able sensation" or TENS electrodes
<jnly (control) over the median
nerve. They found that skin blood
flow quickly and significantly in-
creased during the application of
4-H/ TENS, followed by a rapid and
distinct drop after cessation of stim-
ulation, although skin blood flow re-
mained signilicanti) above the base-
line level by -^30% for 15 minutes
p<jst-stimulation.
This pattern of response was quite
different from that found in the
present stud)\ where a continuous,
although nonsignificant, increase
was .seen even after the cessation of
stimulation. I h e different results
may have various explanations, such
as differences in stimulation intensi-
ties and stimulation sites. In the
present study, motor-level 2-Hz
TENS, causing visible muscle con-
tractions, may have resulted in redis-
tribution of blood from the skin to
the contracting trapezius muscle un-
derneath.''' The finding in the
present study that increases in skin
blood flow wilh motor-level 2-Hz
TENS were not significantly different
from increases in skin blood tlow in
the contralaterai, nonstimulated
shoulder suggests that this mode of
stimulation may not result in true
increases in skin blood flow.
With 15-minute sensory-level TENS,
skin blood flow did not increase in
either the present study using a fre-
quency of 80 Hz or in the study by
Cramp et al." who used a frequenc)'
of 110 Hz at an amplitude causing a
"strong but comfortable sensation."
A blood flow increase of 15% to 20%
should be expected due to the
wanning effect of the PPG probe.
Consequently, a decrease rather than
an increase in skin blood flow might
have been the result of the stimula-
tion, possibly reflecting increased
sympathetic activit)' causing cutane-
ous vasoconstriction and decreased
August 2007
 Blood Flow Changes Following TENS
skin blood flow. This increased sym- fects is advisable during long-term
pathetic activity may be explained monitoring.
by the high stimulation intensity',
which at times was perceived as un-
All authors provided concept/idea/research
pleasant or painful. In contrast to design and writing. Ms MK Sandberg and
these studies, however, a study com- Ms Dahl provided data collection and sub-
prising assessment after repeated jects. Dr ML Sandberg provided data analy-
2-hour sessions per day (sensory- sis, project management, fund procure-
level 80-Hz TENS) in ischemic tissue nnent, facilities/equipment, and institutional
liaisons. The authors thank Alexander Carls-
showed increased skin blood flow.-* son for contribution to the data collection.
The local ethics committee at the Faculty of
In the present study, subliminal Health Sciences, Linkoping University, ap-
TENS with the weakest current in- proved the study.
tensit)' possible (0.5 mA) was chosen
This study was supported by grants from the
as a control and was not expected to
County Council in Ostergotland, Sweden.
affect blood flow. Tliis intensit)' cor-
This article was received June 21, 2006, and
responded to no more than 0.2 times
the sensory threshold. Although skin was accepted March 15. 2007.
blood flow did increase with this
DOI: 10.2522/ptj.20060178
stimulation, it was not significantly
different from the increase in skin
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Number 8 Physical Therapy 1055