Conductive Differences in Electrodes Used with
Transcutaneous Electrical Nerve Stimulation Devices
Michael F Nolan
PHYS THER. 1991; 71:746-751.
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Technical Report
Conductive Differences in Electrodes Used with
Transcutaneous Electrical Nerve Stimulation Devices
Michael F Nolan
The purpose of this study was to document conductive differences among commercially available electrodes used with transcutaneous electrical nerve stimulation (TENS) devices. Impedance within a model system involving a human subject
was cakulatedfrom oscilloscopic tracings of the pulse wavefomz for each of 25
d@erent electrode types. Impedance values rangedfrom 1,000 to 7,800 S1. Possible reasons for these differences are discussed. The observation that electrodes vary
in their impedance and can thereby affect the stimulus applied to the skin raises
the question of whether electrode choice might affect the clinical effectiveness of
TENS. Attention is drawn to the skin electrodes as a variable that may affect the
results of clinical and basic studies involving TENS. [Nolan MF. Conductive dzfferences in electrodes used with transcutaneous electrical nerve stimulation devices.
Pbys Thm: 1991;71:746-751 .]
Key Words: Electrode, Impedance, Transcutaneous electrical nerve stimulation.
Transcutaneous electrical nerve stimulation
is frequently used in
the symptomatic management of acute
and chronic pain conditions.l-l2 Its
attractiveness as a therapeutic modality is based in part on its simplicity
and the ease with which it can be
used.
An important component of the TENS
system is the skin electrode. Early
TENS electrodes were fashioned from
silicone rubber impregnated with carbon particles. Effective transmission of
the electrical pulse necessitated the
use of a coupling agent, typically a
gel, and tape was required to secure
the electrodes in place. Contemporary
electrodes use newly developed poly-
mers as the conducting medium, and
many are prepackaged with hypoallergenic adhesive materials. These newer
electrodes are less messy and easier
to apply and remove than the carbonrubber-gel electrodes. The newer
electrodes, therefore, offer features
that may significantly affect patient
compliance.
Many contemporary electrodes can be
used interchangeably with different
TENS devices. Adapters are also available that allow an even greater number of stimulator-electrode combinations, the claimed value of which is
the ability to create custom-made
stimulating systems, individually designed to meet the specific needs of
MF Nolan, PhD, PT,is Associate Professor of Anatomy and Associate Professor of Neurology, Department of Anatomy, College of Medicine, University of South Florida, 12901 Bruce B Downs
Blvd, Tampa, FL 33612 (USA).
The study protocol was reviewed and approved by the Institutional Review Board of the Universiry
of South Florida, Health Sciences Center.
the patient or the requirements of the
clinical situation.
The ability to use various types of
electrodes with a particular TENS device prompted me and my colleagues
at the University of South Florida
(Tampa, Fla) to question whether the
therapeutic effectiveness of TENS
might be influenced by the choice of
electrodes. To answer this question,
we thought it necessary to first understand how electrodes differ and how
particular types of electrodes might
influence the electrical pulse delivered to the skin. Although these concerns have been addressed for
electro~ardiographicl3~~4
and electroencephalographicl5 electrodes, we
could find no reports in the literature
that directly addressed these issues
for TENS electrodes. The purpose of
this initial study, therefore, was to
document whether differences existed
among commercially available TENS
electrodes based on calculations of
impedance in a model system us-
This ariicle was submitted Atcgusl IG, 1990, and was accepted June 4, 1991.
Physical TherapyNolume
71, Number 10/0ctober 1991
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746 / 51
ing a human subject. The ability to
distinguish electrodes based on their
conductive properties might be helpful in identifying and selecting specific
types of electrodes that might be appropriate for use in studies dealing
more directly with the question of
clinical efficacy.
Twenty-five different commercially
available electrodes were obtained for
use in this study (Appendix). Some
were obtained as part of a TENS device package. Electrodes obtained in
this way were either designed specifically for use with a particular TENS
device or, more commonly, were the
flexible carbon-rubber type. Other
electrodes were obtained directly from
manufacturers of TENS supplies. These
electrodes were typically marketed as
being appropriate for use with more
than one type of TENS device.
All measurements were performed on
a single nondisabled, adult, male subject, who reported being free from
cutaneous, vascular, o r nervous system disease. The subject in this study
was familiar with the sensation of
TENS and consented to participate in
this initial study.
In accordance with routine skin preparation procedures, the skin on the
volar surface of the subject's left forearm and wrist was cleansed with an
alcohol wipe and allowed to air dry. A
matching pair of electrodes was then
applied, one electrode on the skin
over the median nerve in the cubital
fossa and the other electrode on the
skin over the median nerve at the
wrist. Self-adhesive electrodes were
aflixed according to the manufacturers'
instructions. Carbon-rubber electrodes
were coated with a thin layer of gel
(Appendix), which was evenly spread
to completely cover the skin contact
surface, and the electrodes were secured in place by means of a comfortably fitting 2.54cm (I-in) Velcro@*
strip. Excess gel was wiped away after
the lead wires were connected.
Stimulation was delivered using a single channel of a constant-current
TENS device.+ Because the stimulator
used in this study delivered an asymmetrical biphasic pulse, each electrode was cathodal for a period of
time during the pulse cycle and anodal during the remaining time. For
the purpose of this study, the electrode demonstrating a negative deflection on the oscilloscope at the beginning of the pulse cycle was attached
proximally on the subject's forearm.
A dual-channel oscilloscopes was
used to monitor both current and
voltage waveforms. Current was
measured by determining voltage
drop across a resistor placed in series with one lead of the TENS device. Voltage was measured directly
from the oscilloscope. Stimulator
output was initially applied to a
1,000-R resistor to preset the TENS
device to deliver a 200-microsecond
pulse of 10 mA at a frequency of 85
Hz, output settings within the range
of those commonly used in clinical
practice. Changes in peak voltage
from preset values were measured
from oscilloscopic tracings when
the current was redirected by
means of a switch from the resistor
to the subject. Impedance in the
model system from the electrodes
and the body was then calculated by
dividing the peak voltage dropped
by the current.
Only one pair of electrodes was
tested each day to eliminate effects
resulting from cutaneous reactions to
the conducting media, adhesives, o r
stimulating current. Each electrode
pair was tested on two separate occa-
'Velcro USA Inc, 406 Brown Ave, Manchester, NH 03103.
'~electra,Dual-Channel, Model 7720, Medtronic Inc, Neuro Div, 7000 Central Ave NE, Minneapolis,
MN 55432.
sions, with all 25 electrode pairs being tested once before the second
round of trials was begun. New electrodes were used for each test session. All experiments were performed
at the same time each day in a
temperature- and humidity-controlled
environment (temperature was maintained at 22"-23"C, and humidity was
maintained at 66%-70%).
In preliminary experiments carried
out to develop and test the model
system, two effects evolved gradually
when stimulation lasted for more than
10 minutes. These effects were a reduction in the subject's perceived intensity of stimulation and changes in
measured voltage. Perceptual changes
can be attributed to stimulation effects
on cutaneous receptors o r peripheral
nerve conductivity, to the activation of
mechanisms within the central nervous system, o r possibly to some
combination of these effects.l"20 Voltage changes suggest the occurrence
of physical o r chemical changes in the
skin, the electrode-conducting medium complex, or both, that alter resistance to the flow of ~ u r r e n t . ~ l To
-~3
eliminate these effects, all measurements were completed within the first
10 seconds following the onset of
stimulation.
Results
Impedance measurements for both
trials with each pair of electrodes
tested in the model system are presented in the Table. Measured values
ranged from 1,000 to 7,800 R . For
descriptive purposes, electrodes were
classified into three groups based on
naturally occurring breaks in the calculated impedance values. The lowimpedance group demonstrated values ranging between 1,000 and
1,900 0, the medium-impedance
group showed values of 2,100 to
4,400 R, and the high-impedance
group was characterized by impedance measurements of r 5,000 R.
These values d o not represent the
impedance of the electrodes themselves, but rather impedance within
the model system used in this study.
$Model T912 Storage Oscilloscope, Tectronix Inc, Howard Vollum Industrial Park, PO Box 500,
Beaverton, OR 97077.
52 / 747
Physical Therapy/Volume 71, Number 10/October 1991
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Table. Impedance Measurements (in Ohms)for Two Separate Trials with Each Electrode Pair
Low-Impedance Group
Electrode
Number
Medium-impedance Group
Trlal
1
2
With the exception of electrodes 8
and 15, the electrodes in the lowimpedance group were made of
carbon-rubber and used either gel o r
karaya as the conducting medium.
Electrode 8 was a pregelled, selfadhesive electrode, and electrode
15 used a water-moistened, synthetic
conductive adhesive as a coupling
agent. Electrode 8 was the only
single-use electrode in the lowimpedance group.
The medium-impedance group of
electrodes was characterized by
greater diversity with regard to conducting medium. Electrode 2 was a
pregelled, self-adhesive electrode.
Electrode 4 was a moisture-activated
self-adhering electrode. Electrode 22
was a water-coupled electrode designed specifically for use with the
TENS device with which it was packaged. The remaining electrodes in
this group used a synthetic polymer at
the skin-electrode interface. No
carbon-rubber electrodes were found
in this group. Electrodes 2, 4, 7, 10,
and 19 were designed for single use,
whereas electrodes 5, 6, 11, 12, 18, 22,
and 24 were of the reusable type. The
two electrodes in the high-impedance
group (electrodes 1 and 3) were of
Electrode
Number
High-Impedance Group
Trlal
1
2
the pregelled, self-adhering type, both
designed for single use.
Impedance values for most of the electrodes differed for the two trials. Measured differences ranged from 100 to
1,400 fl (Table). Only electrodes 13,
14, and 16 of the low-impedance
group showed identical measurements
for the two test sessions.
Skin reactions were not seen with any
of the electrodes, except for electrode
1.After both trials, a mild redness was
noted beneath the proximal electrode. The redness involved the skin
in contact with the adhesive but not
that beneath the active part of the
electrode. This hyperemic reaction
resolved within 4 hours. No redness
was observed beneath the distal electrode on the volar surface of the subject's wrist.
Discussion
The results of this study indicate that
commercially available TENS electrodes vary in their conductive p r o p
erties and that electrode selection
affects impedance in this model system. Impedance, however, is determined by several elements in addition
to electrodes and conducting me-
Physical TherapyNolume 71, Number 10/0ctober 1991
Electrode
Number
Trlal
1
2
dium. Interelectrode distance and
differences in the thickness and texture of the skin each contribute to
total impedance within the system.
These variables were carefully controlled, however, by the use of a single subject and by the use of fixed
electrode placement sites on the forearm. Differences in impedance attributable to normal anatomic variation
were thus minimized o r eliminated.
Impedance within the model system
was determined by several factors,
including the size of the conducting
surface and the electrical properties
of the conducting medium. Smaller
electrodes will offer greater impedance than larger electrodes. We might
expect, therefore, that the smaller
electrodes in this study would be associated with higher impedance measurements than would electrodes with
larger active areas. The electrodes in
the high-impedance group were the
smallest electrodes tested.
The electrical properties of the material from which the electrodes were
constructed as well as the composition and distribution of the conducting medium may also have alTected
impedance. Several different gels and
a variety of natural and synthetic poly-
Downloaded from http://ptjournal.apta.org/ by guest on September 30, 2016
mers served as conducting media in
this study. All of the carbon-rubber
electrodes using gel as a conducting
medium were classified in the lowimpedance group. This observation
suggests that, as a group, standard
carbon-rubber electrodes used with
commercially available gels offer less
impedance than electrodes used with
other types of conducting media.24
We did not compare the size of the
active area of individual electrodes
with measured impedance values nor
did we analyze the chemical composition of the various conducting substances. An analysis of the interaction
among these factors was considered
beyond the scope of this initial study.
Our objective was rather to demonstrate that commercially available
TENS electrodes vary in their conductive properties and can therefore affect
the amount of stimulation delivered to
the skin. It is not known whether the
relative differences in conduction efficiency observed in this study correlate
with any reported clinical benefits of
Future work in this area
might focus on determining which
particular electrodes might be best
suited for obtaining specific physiological o r clinical results.
Skln Reactions
Several authors2528 have reported
skin reactions to either the stimulating
current itself o r to electrode adhesives and conducting gels. Reported
reactions include mild inflammatory
responses and small punctate bums
in areas of high current density.2',2528
Fisher and Brancaccio2' have shown
that propylene glycol, which is a component of some electrode gels, may
be irritating to the skin. We noted a
skin reaction with only one of the
electrodes tested. We attribute this
response to some component of the
adhesive to which the subject was
sensitive. Because the observed skin
reaction did not occur beneath the
active part of the electrode, but rather
involved the skin in contact with the
adhesive, we feel confident that the
impedance measurements obtained
with these electrodes accurately reflect the impedance within the model
system. We acknowledge, however,
the need for a cautious interpretation
of this conclusion.
Between-Trial Differences
Impedance differences were noted
between trials with the same electrodes for all except three of the electrodes examined (Table). Several
possible explanations for these differences might be advanced. Injury to
the skin could have produced the
observed differences. We think this
explanation is unlikely in view of the
fact that, with the exception of one
electrode previously noted, no skin
reactions were observed, and in that
case the redness involved only the
skin in contact with the adhesive.
Moreover, at least 24 hours was allowed between each testing session.
Microscopic injuries, not detectable
by visual inspection, might have been
produced and might account for the
observed differences, but data to confirm o r eliminate this hypothesis are
not available.
Chemical reactions in the skin or involving the electrodes and conducting
medium may also affect impedance
within the model system. We think
this explanation is also unlikely, because of the low levels of current
used and the short length of time the
current was applied. Rather we suspect that the measured between-trial
differences reflect physical differences
in the composition of the electrodes
themselves in the case of the
pregelled electrodes or those using
natural o r synthetic polymers or in
the distribution of gel in the case of
the carbon-rubber electrodes. Although these factors presumably did
not affect the impedance measurements in this study, they may be of
greater concern in other types of
studies or clinical situations in which
stimulation sessions are of considerably longer duration.
Our purpose in testing each electrode
pair on two separate occasions was to
ensure against technical failures involving the TENS device, battery, o r
lead wires that might have gone undetected had only a single measure-
ment been taken. We were not attempting to assess the reliability of
any particular electrode type. The fact
that between-trial differences were
found using a simple, standardized
protocol that was rigorously followed
suggests the possibility that different
electrodes of the same type might not
be identical in terms of their conductive properties. Future studies might
focus on the question of electrode
reliability and whether conductive
differences among electrodes of the
same type might be a source of variation in clinical response.
Clinical Implications
The results of this study suggest that
TENS electrodes are different in terms
of their conductive properties. The
results d o not address the issue of
which electrodes can be regarded as
poor, good, better, o r best. The ability
to make judgments of this type would
necessitate the development of operative definitions of these terms and
different experimental strategies and
objectives that were not part of this
initial study.
The clinical significance of the conductive differences reported in this
article is unclear at present. Electrodeinduced effects may be small with
TENS devices that effectively maintain
a constant current, more pronounced
with TENS units that are less able to
d o so, and significant if constantvoltage TENS units are used.z+sl The
observations reported in this article
draw attention to electrodes and conducting media as potentially important variables in studies involving
TENS. Additional research will be required to better understand how
TENS affects nervous system function
and in particular how this modality
can be effectively used to reduce o r
eliminate pain. Further efforts in this
regard might help explain some of
the contradictory findings in the TENS
literature and clarlfy a variety of clinically important issues.
The results of this study demonstrate
that TENS electrodes vary in their
Physical TherapyNolume 71, Number 10/0ctober 1991
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-
Appendlx. Descriptive Charactmistics ofIndividua1 Electrodes Used with Transcutaneous Electrical N m e Stimulation Devices
1. Uni-Pulse 600': self-adhering, single use, pregelled, foam
2. Uni-Thin@650': self-adhering, single use, pregelled
3. Uni-Pulse 685*: self-adhering, single use, pregelled, cloth
4. Tenzcare 6221t: water activated, single use, conductive adhesive
5. Uni-Patch Multi-Dap 695': self-adhering, reusable, synthetic polymer, foam
6. Uni-Patch E n c o r e 693*: self-adhering, reusable, PolyHesive gel*
7. SUE@: self-adhering, single use, karaya with foam backing
8. Staoderm I I I ~ self-adhering,
~:
single use, pregelled
9. Medtronic Model 3795':
reusable, carbon-rubber, chloride-free Neuromodo gel'
10. Comfort E a s e 7791+: self-adhering, single use, synthetic polymer
11. Neuroaie 3798': self-adhering, reusable, synthetic polymer
12. Neuroaido 3799 (HH)': self-adhering, reusable, hydrophilic synthetic polymer
13. EMPl Model 94050" reusable, carbon-rubber, chloride-free gel
14. Dermapado*': self-adhering, reusable, karaya with carbon-rubber backing
15. Tenzcare 6225t: self-adhering, reusable, water activated, conductive adhesive
16. WITPAPtt: self-adhering, reusable, karaya with carbon-rubber backing
17. Carbon-rubbertt: reusable, salt-free Wit Gelott
18. PALS@ 85610OW:self-adhering, reusable, PolyHesive gel*
19. Protectom 142-KC5§:self-adhering, single use, polymer, cloth
20. Carbon-rubber5§:reusable, salt-free Spectram 360 gel1Il1
21. Carbon-rubberX#:reusable, chloride-free conductive gel***
22. Sponge Electrodettt: reusable, water-conducting medium
23. Bioform@**: reusable, carbon-rubber, chloride-free Biogel@**
24. Sentry Silver Circuit Dura Durmo 50015s5:self-adhering, reusable, synthetic polymer
25. Carbon-r~bber~l~~~l:
reusable, chloride-free Lectron IIm gel"'
*Uni-Patch Inc, 1313 Grand Blvd W, PO Box 271, Wabasha, MN 55981.
"Medical Designs Inc, 929 Eastwind Dr, Ste 201, Westerville, OH 43081.
t3M Medical-Surgical Div, Bldg 225-5S, 3M Center, St Paul, MN 55144-1000.
ll'l~arkerlaboratories Inc, 307 Washington St, Orange, NJ 07050.
fValleylab Inc, Boulder, CO 80301.
"NTRON
"MPI
***MedicalAdhesives Inc, Columbus, OH 43215.
Inc, Fridley, MN 55432.
IIStaodynamicsInc, 1225 Florida Ave, PO Box 1379, Longmont,
CO 80502-1379.
Electronics Inc, PO Box 7000. San Rafael, CA 94901.
t f f ~ a i nSuppresssion labs Inc, Elmwood Park, NJ 07407.
***~iostemInc, Princeton, NJ 08540.
'~edtronic Inc, Neuro Div, 7000 Central Ave NE, Minneapolis, MN 55432.
"§Sentry Medical Products Inc, Santa Ana, CA 92707.
**Codman & Shunleff Inc, Randolph, MA 02368.
ll1l1kens
X Tec, Orlando, FL 32804.
t?Xlallant International Trade Inc, Roselle, NJ 07203.
'"~harmaceutical
07114.
**~xlegaardManufacturing Co Ltd, Huntington Beach, CA 92646.
. .
conductive ~ r o ~ e r t i eThus,
s . like amolitude., z~ u l s eduration. and frez
quency, electrodes and conducting
media represent variables that may
affect the ~ain-relieving
- effects of
TENS, These observations emphasize
the need to include information about
electrodes in reports concerning
TENS and call attention to the importance of controlling for this source of
variability in future clinical and basic
science studies.
-
Innovations Inc, 897 Frelinghuysen Ave, Newark, NJ
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Conductive Differences in Electrodes Used with
Transcutaneous Electrical Nerve Stimulation Devices
Michael F Nolan
PHYS THER. 1991; 71:746-751.
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