Transcutaneous Electrical Nerve Stimulation in the
Relief of Primary Dysmenorrhea
The purpose of this study was to replicate a previous study to determine the
effectiveness of acupuncture-like transcutaneous electrical nerve stimulation in
treating primary dysmenorrhea. Twenty-one women with dysmenorrhea received
a placebo pill or 30 minutes of acupuncture-like TENS. All subjects completed two
pain questionnaires before treatment; immediately posttreatment; 30, 60, 120,
and 180 minutes posttreatment; and the next morning upon awakening. Each
woman also participated in a separate study measuring electrical resistance at
four auricular acupuncture points before and immediately after treatment. The
data were analyzed with a two-factor repeated-measures analysis of variance,
which revealed statistical significance over time but not for group or interaction
between group and time. Results revealed an average pain relief of at least 50%
immediately posttreatment, indicating that acupuncture-like TENS may be useful
for dysmenorrheic pain. This study also suggests that auriculotherapy via
acupressure may relieve the pain ofprimary dysmenorrhea. [Lewers D, Clelland
JA, JacksonJR,et al: Transcutaneous electrical nerve stimulation in the relief of
primary dysmenorrhea. Phys Ther 693-9, 1989]
Deborah Lewers
Jo Ann Clelland
James R Jackson
R Edward Varner
Joan Bergman
Key Words: Acupuncture/acupressure, Dysmenorrhea, Pain, Physical therapy,
Transcutaneous electrical nerve stimulation.
Dysmenorrhea, or painful menstruation, affects 5296 of postpubescent
women with 10% of these women
incapacitated for one to three days per
month.1 Dysmenorrhea appears in two
forms: 1) primary and 2) secondary.
Primary dysmenorrhea is defined as
pain during menstruation that is not
the result of a macroscopic pelvic
pathological condition; that is, the
woman has had a normal pelvic
examination. Secondary dysmenorrhea
is the result of a macroscopic pelvic
pathological condition.1 Symptoms seen
D Lewers, MS, is Physical Therapist, Spain Rehabilitation Center, University of Alabama Hospitals, 1717
6th Ave S, Birmingham, AL 35294. She was a graduate student, Division of Physical Therapy, School of
Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35209, when this
study was conducted. This study was completed in partial fulfillment of Ms Lewers's master's degree
program requirements. Address correspondence to 5608 9th Ave S, Birmingham, AL 35212 (USA).
J Clelland, MS, is Associate Professor and Associate Director, Division of Physical Therapy, School of
Health Related Professions, The University of Alabama at Birmingham.
J Jackson, PhD, is Assistant Professor, Office of Educational Development, School of Medicine, The
University of Alabama at Birmingham.
R Varner, MD, is Assistant Professor and Director, Division of Primary Obstetrics and Gynecology,
Department of Obstetrics and Gynecology, The University of Alabama at Birmingham.
J Bergman, PhD, is Professor, Division of Physical Therapy, and Director, Physical Therapy Division,
Sparks Center, The University of Alabama at Birmingham.
This article was submitted September 16, 1987; was with the authors for revision for 15 weeks; and
was accepted May 26, 1988.
Physical Therapy/Volume 69, Number 1/Januaty 1989
in both forms include spasmodic pain
over the low abdomen, possibly
radiating to the anterior thigh; low back
pain; nausea; diarrhea; headache;
fatigue; and sometimes syncope and
collapse. These symptoms can begin a
few hours or days before menstruation
and last up to two or three days.1
The causes of primary dysmenorrhea
have not been defined specifically, but
many possible causes have been
presented. Psychologic factors may be
possible as in any case of pain,1 but no
conclusive studies have shown these
factors as the cause.2 Endocrine factors
have been suggested because primary
dysmenorrhea occurs only during
ovulatory cycles. Recent studies
propose that vasopressin levels are
increased during the menstrual phase
of primary dysmenorrheic women
resulting in dysrhythmic uterine
contractions or cramps.1 Cervical
3/17
obstruction or stenosis has been
suggested since the days of
Hippocrates,3 but no evidence has been
reported to suggest this condition as a
cause of primary dysmenorrhea.1
Recent studies have indicated an
increase in intrauterine prostaglandin
production and a decrease in ovarian
steroid hormone as causes of primary
dysmenorrhea.1-4 These changes result
in an elevated intrauterine pressure,
which subsequently results in a
decreased uterine blood flow,
ischemia, and pain.1,4 The
prostaglandins that are released, mainly
PGF2a and PGE2, also sensitize the
nerves in the uterus to the action of
chemical and physical stimuli.1
Methods of treatment for dysmenorrhea range from prostaglandin
synthetase inhibitors and oral
contraceptives to noninvasive methods
such as heat packs, biofeedback,
relaxation techniques, and
acupressure.5 Traditional acupuncture
has been documented as successful by
Walker and Katz6 and Steinberger,7
resulting in an attempt by other
investigators to use transcutaneous
electrical nerve stimulation over
traditional acupuncture points to
achieve the same success.8-10
Transcutaneous electrical nerve
stimulation is an accepted method of
noninvasive, nonnarcotic pain control.5
It has been used successfully in control
of postoperative pain11,12; low back
pain13,14; labor and delivery15,16; and
cystitis, pancreatitis, angina pectoris,
thrombophlebitis, and
dysmenorrhea.5,17 Conventional TENS
and "acupuncture-like" TENS are used
most frequently for treatment.
Conventional TENS requires a high
pulse rate with a low intensity, whereas
acupuncture-like TENS uses a low
pulse rate with a high intensity, often as
high as the patient can tolerate. Kroth
studied relief of dysmenorrhea with
acupuncture-like TENS in 10 women
and saw significant pain relief, but no
control group was used.10 Janke studied
the effectiveness of acupuncture-like
TENS using an experimental group that
received treatment on acupuncture
points and a control group that
received conventional TENS on points
not believed to be associated with
dysmenorrhea.9 She reported a 50%
decrease in pain for both groups,
suggesting that any form of electrical
stimulation may relieve the pain of
primary dysmenorrhea. Mannheimer
and Whalen compared the effectiveness
of conventional TENS and
acupuncture-like TENS and found
significant relief in primary
dysmenorrhea with both forms.5
Neighbors et al studied 20 women, 10
receiving treatment of dysmenorrhea
with acupuncture-like TENS and 10
receiving a placebo pill. Their results
supported the hypothesis that a single
treatment with acupuncture-like TENS
would significantly decrease the pain of
primary dysmenorrhea.8
Acupuncture-like TENS is believed to
work via release of endorphins in the
brain.5 Endorphins are natural opiates
that block the input of pain, possibly
via the dorsolateral funiculus. These
endorphins bind to receptors in the
periaqueductal gray matter and lead to
an antidromic inhibitory process that
blocks the nociceptive impulse from
reaching the substantia gelantinosa.18
The purpose of this study was to
replicate the study by Neighbors et al8
to determine the effectiveness of
acupuncture-like TENS in the treatment
of primary dysmenorrhea. Because
physical therapists often use TENS to
decrease pain, we hoped to discover
whether it can be used to decrease
pain for the large number of women
who are affected by dysmenorrhea. The
hypothesis of this study was that a
single treatment with acupuncture-like
TENS would reduce significantly the
pain of primary dysmenorrhea.
*Staodynamics, Inc, PO Box 1379, Longmont, CO 80502-1379.
†
NTRON International Sales Co, 3833 Redwood Hwy, PO Box 7000, San Rafael, CA 94912.
‡
1 in = 2.54 cm.
18/4
Method
Subjects
Twenty-one women who were
experiencing self-reported
dysmenorrhea volunteered to
participate in this study. These women
all reported having a pelvic
examination within the previous two
years that revealed no pathological
problems or secondary dysmenorrhea.
The subjects were assigned randomly
to one of two groups: 1) an
Experimental Group (n = 10) that
received TENS treatment or 2) a
Control Group (n = 11) that received a
placebo pill. This study received the
approval of the Institutional Review
Board for Human Use, The University
of Alabama at Birmingham.
Protocol
Each subject notified the investigator
upon onset of her pain, and a time was
scheduled for that day for either a
TENS treatment (Experimental Group)
or treatment with a placebo pill
(Control Group). The treatment was
administered in a clinical laboratory
room at The University of Alabama at
Birmingham. The subjects were
instructed to take no pain medication
for at least four hours before treatment.
Before beginning treatment, the
subjects completed a menstrual history
questionnaire, a consent form, the pain
rating index (PRI) of the McGill Pain
Questionnaire (Appendix 1), and a
visual analog scale (VAS) (Appendix 2).
The PRI and VAS were used to establish
a baseline level of pain.
At this point, each subject participated
in a study by Reynolds et al19 that
involved measuring the electrical
conductance at four auricular
acupuncture points, bilaterally, with the
Stayodyn Insight stimulator.* The
auricular acupuncture points assessed
were the uterus, endocrine, low back,
and ovary.19 After this portion of the
Reynolds et al study,19 each Control
Group subject in our study took a
placebo pill with a glass of water in the
presence of the investigator (D.L.) The
subject was then positioned prone on a
plinth for 30 minutes with pillows
under her head, abdomen, and lower
Physical Therapy/Volume 69, Number 1/January 1989
that allows a pain index to be
calculated. The VAS is composed of a
10-cm horizontal line with the words
"no pain" on the left and "pain as bad
as it could be" on the right. The subject
is instructed to make a mark on the
line at a point that represents her pain
level at that time. These pain scales
were completed immediately before
treatment before the first measurement
of conductance at auricular points and
immediately posttreatment in the
presence of the investigator before the
second measurement of conductance.
After the measurement of conductance
at auricular points was taken, the
subject was dismissed and instructed to
complete the pain scales again in 30
minutes, 60 minutes, 120 minutes, 180
minutes, and the next morning upon
awakening. Each subject was instructed
not to take any pain medication until
after completion of all the pain scales
unless it was absolutely necessary. A
self-addressed, stamped envelope was
provided for return of the completed
pain scales.
Data Analysis
The values obtained pretreatment and
posttreatment from the VAS and the PRI
were analyzed using a two-factor
Fig. 1. Electrode placement over four classical acupuncture points: Spleen 6, Stomach
repeated-measures analysis of variance
36, Bladder 21, Bladder 29.
(ANOVA). An alpha level of .05 was
chosen as the criterion for statistical
legs. The subjects in the Experimental
adjustments in intensity were needed
significance in all tests. A pair-wise
Group were positioned in the same
to attain the subject's tolerance level,
comparison using Tukey's Honestly
manner as those in the Control Group.
they were made at this time. The
Significant Difference (HSD) test was
Two NTRON 2600 TENS units† were
treatment was given for a total of 30
used
to follow up statistically significant
used, and eight 1.5-in‡ diameter karaya
minutes, and the electrodes were then
main effects over time.
electrodes were placed bilaterally on
removed.
the following acupuncture points:
To better assess clinical significance,
Stomach 36, Spleen 6, and Bladder 21
The posttreatment pain scales were
the percentage of change was
and 29 (Fig. 1).
completed immediately after the TENS
calculated for each subject, and the
treatment for the Experimental Group
mean of these values was calculated to
The following TENS variables were
and immediately after the 30-minute
obtain a mean percentage pain
used: 1) the lowest rate possible (1
rest period for the Control Group. After
reduction value. In addition, the
pulse/sec), 2) the highest intensity that
completion of the pain scales, the same
number of subjects experiencing at
was tolerable for the subject for 30
auricular acupuncture points of each
least a 50% pain reduction at each of
minutes, and 3) the lowest possible
subject were measured for electrical
the
posttreatment times was noted.
pulse duration (40 msec). If the subject
conductance by Reynolds et al.19
could tolerate the highest intensity
Results
stimulation, the duration of the pulse
Pain Measurement
was increased to the point of tolerance.
The subjects ranged in age from 20 to
Tolerance was defined as the level at
The subject's pain level was assessed
38 years ( = 25.9 years), with a mean
which the subjects asked the
using the PRI and the VAS. The PRI
age of menarche of 11.6 years for the
investigator to stop increasing the
gives the subject a choice of words
Experimental Group and 12.1 years for
stimulation. The TENS unit was
describing her pain at that moment.
the Control Group. The main
rechecked after 5 minutes. If
The words are assigned a rank value
complaints from the subjects were
Physical Therapy/Volume 69, Number 1/January 1989
5/19
abdominal pain, cramps, and low back
pain. Ten subjects also complained of
irritability, headaches, and general
aching.
Twenty-one subjects were treated in
this study with pain scales completed
immediately posttreatment; at 30, 60,
120, and 180 minutes posttreatment;
and the next morning. Two subjects in
the Experimental Group were the only
subjects who did not complete the
information at all of the posttreatment
measurement times because they were
asleep at that time and needing to take
additional medication. They did not
complete the scales at 180 minutes
posttreatment and the next morning.
Given our small sample size, we did
not want to drop these two subjects
from the study because they were
missing the last two of their seven data
points. Thus, we substituted their pain
scores at 120 minutes posttreatment for
their missing scores at 180 minutes
posttreatment and the next morning;
that is, we assumed no change after
120 minutes for these subjects. We
analyzed the data with and without the
two subjects, and found the same
results in each analysis.
Figures 2 and 3 present mean pain
values for the Experimental and
Control Groups using the PRI and
VAS, respectively. The ANOVAs
revealed statistical significance
(p < .001) only in time of
measurement for both the VAS and
PRI (Tabs. 1, 2). Group and
interaction between group and time
were not statistically significant for
either the PRI or the VAS. Thus, pain
relief was approximately the same for
the two groups over time. For both
the PRI and the VAS, Tukey's HSD
test showed a statistically significant
difference (p < .05) between the
pretreatment mean and each
posttreatment mean, but we found no
statistically significant differences
among the six posttreatment means.
At the initial posttreatment
measurement time, the VAS revealed a
47.1% decrease in pain for the Control
Group and a 65.2% decrease in pain
for the Experimental Group, and the
PRI revealed a 55.6% reduction in pain
for the Control Group and a 61.9%
20/6
E=Experimental
C=Control
Fig. 2 . Mean pain values for Experimental and Control Groups on the pain rating
index of the McGill Pain Questionnaire.
E=Experimental
C=Control
Fig. 3 . Mean pain values for Experimental and Control Groups on the visual analog
scale.
reduction in pain for the Experimental
Group. The number of subjects
experiencing at least 50% pain
reduction are shown in Table 3.
The median Pearson product-moment
correlation between the VAS and the
PRI over the seven measurement times
was .72 (p < .05). This value represents
a strong positive relationship between
the two measures.
Discussion
As research into the cause of primary
dysmenorrheic pain continues to
demonstrate that the cause is not
psychological,12 more research is being
conducted to discover ways to decrease
and hopefully eliminate this pain for
many women. Some current research
has focused on acupuncture and TENS.
Steinberger used acupuncture at four
acupuncture points for five consecutive
days before the menstrual cycle of 48
women.7 Of those 48 subjects, 58.3%
had total cessation of pain before and
during menstruation, and 25% had
greatly decreased symptoms. The pain
relief or pain reduction lasted up to six
months for these women. 7 Helms used
acupuncture on 43 dysmenorrheic
women who were divided into four
groups: 1) the Real Acupuncture Group
(n = 11), 2) the Placebo Acupuncture
Group (n = 11), 3) the Standard
Control Group (n = 11), and 4) the
Visitation Control Group (n = 10).17
Physical Therapy/Volume 69, Number 1/January 1989
T a b l e 1 . Analysis of Variance Summary for Visual Analog Scale
Source
Group
Within cells
Time of measurement
Group x time
Within cells
df
1
19
6
6
114
SS
MS
F
52.480
324.546
52.480
131.499
21.917
10.118
5.055
246.924
0.843
2.166
0.389
3.072
P
NS
17.081
<.001 a
NS
a
p < .05.
T a b l e 2 . Analysis of Variance Summary for Pain Rating Index of McGill Pain
Questionnaire
Source
Group
Within cells
Time of measurement
Group x time
Within cells
SS
MS
1509.190
11303.273
1509.190
595.909
2.537
19
6
6265.545
1044.258
6
114
634.498
10832.564
105.750
95.022
10.990
1.113
df
1
F
P
NS
<.001 a
NS
a
p < .05.
Although the results of the study were
not statistically significant, 10 subjects
in the Real Acupuncture Group, 4
subjects in the Placebo Acupuncture
Group, 2 subjects in the Standard
Control Group, and 1 subject in the
Visitation Control Group showed
improvement. Improvement was
defined as an average posttreatment
score of less than half of the
pretreatment pain score.17 Mannheimer
and Whalen compared the effectiveness
of conventional TENS and
acupuncture-like TENS and found
significant relief of primary
dysmenorrhea with both forms.5 Kroth,
in an unpublished study, used
acupuncture-like TENS to treat 10
women with primary dysmenorrhea.10
She found that all 10 subjects
experienced more than 50% pain
reduction 180 minutes after treatment.
She, however, did not use a control
group. 10 Janke followed up her study
by treating women with
acupuncture-like TENS using a sham
TENS for a control group.9 She found
both groups to have a statistically
significant reduction in pain, resulting
in the rejection of the proposed
hypothesis that a single treatment with
acupuncture-like TENS would reduce
the pain of primary dysmenorrhea.9
Neighbors et al in another follow-up
study treated 10 women with
acupuncture-like TENS and 10 women
with a placebo pill.8 They found a
statistically significant reduction in pain
immediately posttreatment for subjects
treated with acupuncture-like TENS,
with 7 experimental subjects receiving
at least 50% relief of pain and only 1
control subject receiving the same
relief.8
All of these studies showed significant
pain relief for the subjects receiving
acupuncture or acupuncture-like TENS.
Our study was an exact duplicate of the
Neighbors et al study8 and, therefore,
should have revealed a significant
difference between the groups treated
Physical Therapy/Volume 69, Number 1/January 1989
with acupuncture-like TENS and the
placebo group. The results from our
study indicated that the Control and
Experimental Groups received
approximately the same amount of pain
relief. The fact that the Control Group
in this study also received pain relief,
whereas the control group in the
Neighbors et al study8 did not, may be
due to the fact that all of our subjects
participated in a concurrent study
determining electrical conductance at
auricular acupuncture points.19 The
control subjects in the Neighbors et al
study8 received only a placebo pill. The
auricle has a rich sensory innervation
that has led investigators to believe that
stimulation to the auricle may affect
different areas of the body, depending
on the area stimulated. Investigators
have suggested that there is a link
between sensory nerves of the auricle
and the central nervous system that
may produce analgesic effects.20
Because the probe from the Staodyn
Insight stimulation was placed on four
bilateral auricular points of each
subject for determination of electrical
conductance at those points, each of
those points was tactilely stimulated.
That is, although the points were not
stimulated electrically, they were
treated by acupressure. Thus, the
acupressure treatment that the Control
Group received may have decreased
their pain.
Another factor that may have
contributed to decrease in pain for the
Control Group may have been the
placebo effect.21 The 47.1% and 55.6%
reduction in pain for the VAS and PRI,
respectively, experienced by the
Control Group cannot be attributed
totally to the placebo effect, but may be
due to the treatment received through
the Reynolds et al study.19
This study did reveal a significant
decrease in pain over time for both the
Control Group and the Experimental
Group. Decreases in pain lasting as
long as hours and days have been
documented by other researchers after
treatment with TENS.14 We attempted to
control for other causes for the
continued decrease in pain over time
by requesting that the subjects take no
pain medication if possible until all
7/21
data were collected and by recording
their pain level after a night's sleep.
Table 3 . Number of Subjects Experiencing at Least 50% Pain Reduction as Measured
by Visual Analog Scale (VAS) and Pain Rating Index (PRI) of McGill Pain Questionnaire
The limitations of this study include
the small sample size and the fact that
each subject participated in the
VAS
PRI
Reynolds et al study19 and received a
Control
Control
Experimental
Experimental
treatment by acupressure to auricular
(n = 10)
(n = 10)
(n = 11)
(n = 11)
points. The possibility that auricular
stimulation reduced the pain of
Immediately posttreatment 4
8
6
8
primary dysmenorrhea for the Control
4
7
30 min posttreatment
6
8
Group in this study suggests the need
7
60 min posttreatment
5
6
8
for a study of the effect of true
auriculotherapy on primary
7
7
7
120 min posttreatment
9
dysmenorrhea. Although the results of
9
9
180 min posttreatment
8
10
this study did not show a statistically
Next morning
8
9
9
8
significant difference between groups,
an average of at least 50% pain
reduction was noted for both groups.
For this reason, acupuncture-like TENS
is a possible solution for women who
a
suffer
from severe dysmenorrhea and
Appendix 1 - Pain Rating Index of McGill Pain Questionnaire
do not experience pain relief with
other forms of treatment. Because of
Place a circle around only those words that describe the pain you are experiencing right now.
the large number of women affected
Remember you do not have to circle a word from each group if you do not feel any of them apply.
by dysmenorrhea and because 10% of
these women are incapacitated by this
1
2
3
4
condition,1 continued research into
Jumping
Flickering
Pricking
Sharp
the effects of TENS and
Quivering
Flashing
Boring
Cutting
auriculotherapy on primary
Pulsing
Shooting
Drilling
Lacerating
dysmenorrhea is warranted.
Throbbing
Stabbing
Beating
Pounding
5
Pinching
Pressing
Gnawing
Cramping
Crushing
Lancinating
Conclusion
6
Tugging
Pulling
Wrenching
7
Hot
Burning
Scalding
Searing
8
Tingling
Itchy
Smarting
Stinging
In a group of women experiencing
the pain of primary dysmenorrhea,
acupuncture-like TENS and a placebo
pill were used as treatments, and the
amount of pain relief was recorded at
9
10
11
12
various posttreatment times. The
Dull
Tender
Tiring
Sickening
results of this study revealed a
Sore
Taut
Exhausting
Suffocating
statistically significant reduction in
Hurting
Rasping
Aching
Splitting
pain over time for the Control and
Heavy
Experimental Groups. We found no
14
13
15
16
statistically significant difference in
Fearful
Punishing
Annoying
Wretched
pain relief between the groups. Both
Frightful
Grueling
Blinding
Troublesome
groups showed an average of at least
Terrifying
Cruel
Miserable
50% reduction in pain immediately
Vicious
Intense
posttreatment.
The decrease in pain
Killing
Unbearable
for
the
Control
Group may have been
17
18
19
20
due
to
their
participation
in another
Spreading
Tight
Nagging
Cool
study
that
involved
determining
the
Radiating
Numb
Cold
Nauseating
electrical conductance at four
Penetrating
Drawing
Freezing
Agonizing
Piercing
Squeezing
Dreadful
auricular acupuncture points. The
Tearing
Torturing
decrease in pain for the Experimental
Number
Time
Group may have resulted from a
combination of the acupuncture-like
TENS
and auricular acupressure
a
Adapted from Melzack R (ed), Pain Measurement and Assessment, New York, NY, Raven Press,
1983, by participation in the other
provided
pp 41-47.
study.
22/8
Physical Therapy/Volume 69, Number 1/January 1989
Appendix 2.
Visual Analog Scale
Number
Place a vertical line at the point you feel best describes the level of pain you feel right now.
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
No Pain
Pain as bad as it could be
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Physical Therapy/Volume 69, Number 1/January 1989
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