Efficacy of Sensory Transcutaneous Electrical Nerve Stimulation on Perceived Pain and Gait Patterns in Individuals With Experimental Knee Pain



      To examine the effect of experimental knee pain on perceived knee pain and gait patterns and to examine the efficacy of transcutaneous electrical nerve stimulation (TENS) on perceived knee pain and pain-induced knee gait mechanics.


      Crossover trial.


      Biomechanics laboratory.


      Recreationally active, individuals without musculoskeletal pain aged 18 to 35 years (N=30).


      Thirty able-bodied individuals were assigned to either a TENS (n=15) or a placebo (n=15) group. All participants completed 3 experimental sessions in a counterbalanced order separated by 2 days: (1) hypertonic saline infusion (5% NaCl); (2) isotonic saline infusion (0.9% NaCl); and (3) control. Each group received sensory electrical stimulation or placebo treatment for 20 minutes, respectively.

      Main Outcome Measures

      Perceived pain was collected every 2 minutes using a 10-cm visual analog scale (VAS) for 50 minutes and analyzed using a mixed model analysis of covariance with repeated measures. Gait analyses were performed at baseline, infusion, and treatment. Sagittal and frontal knee angles and internal net joint torque across the entire stance were analyzed using a functional data analysis approach.


      Hypertonic saline infusion increased perceived pain (4/10cm on a VAS; P<.05) and altered right knee angle (more flexion and less abduction; P<.05) and internal net joint torque (less extension and greater abduction; P<.05) across various stance phases. TENS treatment reduced perceived pain and improved right sagittal gait abnormalities as compared with placebo treatment (P<.05).


      This pain model increases perceived pain and induces compensatory gait patterns in a way that indicates potential quadriceps weakness. However, TENS treatment effectively reduces perceived pain and restores pain-induced gait abnormalities in sagittal knee mechanics.


      List of abbreviations:

      EKP (experimental knee pain), OA (osteoarthritis), TENS (transcutaneous electrical nerve stimulation), VAS (visual analog scale)
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        • Jahn K.
        • Zwergal A.
        • Schniepp R.
        Gait disturbances in old age: classification, diagnosis, and treatment from a neurological perspective.
        Dtsch Arztebl Int. 2010; 107: 306-315
        • An K.N.
        Muscle force and its role in joint dynamic stability.
        Clin Orthop Relat Res. 2002; : S37-S42
        • Henriksen M.
        • Graven-Nielsen T.
        • Aaboe J.
        • Andriacchi T.P.
        • Bliddal H.
        Gait changes in patients with knee osteoarthritis are replicated by experimental knee pain.
        Arthritis Care Res. 2010; 62: 501-509
        • Seeley M.K.
        • Park J.
        • King D.
        • Hopkins J.T.
        A novel experimental knee-pain model affects perceived pain and movement biomechanics.
        J Athl Train. 2013; 48: 337-345
        • Denning W.M.
        • Woodland S.
        • Winward J.G.
        • et al.
        The influence of experimental anterior knee pain during running on electromyography and articular cartilage metabolism.
        Osteoarthritis Cartilage. 2014; 22: 1111-1119
        • Hodges P.W.
        • Mellor R.
        • Crossley K.
        • Bennell K.
        Pain induced by injection of hypertonic saline into the infrapatellar fat pad and effect on coordination of the quadriceps muscles.
        Arthritis Rheum. 2009; 61: 70-77
        • Andersen R.E.
        • Crespo C.J.
        • Ling S.M.
        • Bathon J.M.
        • Bartlett S.J.
        Prevalence of significant knee pain among older Americans: results from the Third National Health and Nutrition Examination Survey.
        J Am Geriatr Soc. 1999; 47: 1435-1438
        • Son S.J.
        • Kim H.
        • Seeley M.K.
        • Feland J.B.
        • Hopkins J.T.
        Effects of transcutaneous electrical nerve stimulation on quadriceps function in individuals with experimental knee pain.
        Scand J Med Sci Sports. 2016; 26: 1080-1090
        • Miyazaki T.
        • Wada M.
        • Kawahara H.
        • Sato M.
        • Baba H.
        • Shimada S.
        Dynamic load at baseline can predict radiographic disease progression in medial compartment knee osteoarthritis.
        Ann Rheum Dis. 2002; 61: 617-622
        • Baliunas A.J.
        • Hurwitz D.E.
        • Ryals A.B.
        • et al.
        Increased knee joint loads during walking are present in subjects with knee osteoarthritis.
        Osteoarthritis Cartilage. 2002; 10: 573-579
        • Grodzinsky A.J.
        • Levenston M.E.
        • Jin M.
        • Frank E.H.
        Cartilage tissue remodeling in response to mechanical forces.
        Annu Rev Biomed Eng. 2000; 2: 691-713
        • Petersson I.F.
        • Boegard T.
        • Dahlstrom J.
        • Svensson B.
        • Heinegard D.
        • Saxne T.
        Bone scan and serum markers of bone and cartilage in patients with knee pain and osteoarthritis.
        Osteoarthritis Cartilage. 1998; 6: 33-39
        • Andriacchi T.P.
        • Mundermann A.
        • Smith R.L.
        • Alexander E.J.
        • Dyrby C.O.
        • Koo S.
        A framework for the in vivo pathomechanics of osteoarthritis at the knee.
        Ann Biomed Eng. 2004; 32: 447-457
        • Murray C.J.
        • Richards M.A.
        • Newton J.N.
        • et al.
        UK health performance: findings of the Global Burden of Disease Study 2010.
        Lancet. 2013; 381: 997-1020
        • Andriacchi T.P.
        • Mundermann A.
        The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis.
        Curr Opin Rheumatol. 2006; 18: 514-518
        • Bennell K.
        • Hodges P.
        • Mellor R.
        • Bexander C.
        • Souvlis T.
        The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad.
        J Orthop Res. 2004; 22: 116-121
        • Dye S.F.
        • Vaupel G.L.
        • Dye C.C.
        Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia.
        Am J Sports Med. 1998; 26: 773-777
        • Garland A.
        • Jordan J.E.
        • Necheles J.
        • et al.
        Hypertonicity, but not hypothermia, elicits substance P release from rat C-fiber neurons in primary culture.
        J Clin Invest. 1995; 95: 2359-2366
        • Felipe C.D.
        • Herrero J.F.
        • O'Brien J.A.
        • et al.
        Altered nociception, analgesia and aggression in mice lacking the receptor for substance P.
        Nature. 1998; 392: 394-397
        • Bjordal J.M.
        • Johnson M.I.
        • Lopes-Martins R.A.
        • Bogen B.
        • Chow R.
        • Ljunggren A.E.
        Short-term efficacy of physical interventions in osteoarthritic knee pain: a systematic review and meta-analysis of randomised placebo-controlled trials.
        BMC Musculoskelet Disord. 2007; 8: 51
        • Johnson M.
        • Martinson M.
        Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a meta-analysis of randomized controlled trials.
        Pain. 2007; 130: 157-165
        • Harkey M.S.
        • Gribble P.A.
        • Pietrosimone B.G.
        Disinhibitory interventions and voluntary quadriceps activation: a systematic review.
        J Athl Train. 2014; 49: 411-421
        • Cheing G.L.
        • Hui-Chan C.W.
        Would the addition of TENS to exercise training produce better physical performance outcomes in people with knee osteoarthritis than either intervention alone?.
        Clin Rehabil. 2004; 18: 487-497
        • Ounpuu S.
        The biomechanics of walking and running.
        Clin Sports Med. 1994; 13: 843-863
        • Hopkins J.
        • Ingersoll C.D.
        • Edwards J.
        • Klootwyk T.E.
        Cryotherapy and transcutaneous electric neuromuscular stimulation decrease arthrogenic muscle inhibition of the vastus medialis after knee joint effusion.
        J Athl Train. 2002; 37: 25-31
        • Cappozzo A.
        Gait analysis methodology.
        Hum Mov Sci. 1984; 3: 27-50
        • Kim H.
        • Son S.
        • Seeley M.K.
        • Hopkins J.T.
        Functional fatigue alters lower-extremity neuromechanics during a forward-side jump.
        Int J Sports Med. 2015; 36: 1192-1200
        • Favre J.
        • Erhart-Hledik J.C.
        • Andriacchi T.P.
        Age-related differences in sagittal-plane knee function at heel-strike of walking are increased in osteoarthritic patients.
        Osteoarthritis Cartilage. 2014; 22: 464-471
        • Mündermann A.
        • Dyrby C.O.
        • Andriacchi T.P.
        Secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking.
        Arthritis Rheum. 2005; 52: 2835-2844
        • DeVita P.
        • Hortobagyi T.
        • Barrier J.
        Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation.
        Med Sci Sports Exerc. 1998; 30: 1481-1488
        • Devita P.
        • Hortobagyi T.
        • Barrier J.
        • et al.
        Gait adaptations before and after anterior cruciate ligament reconstruction surgery.
        Med Sci Sports Exerc. 1997; 29: 853-859
        • Torry M.R.
        • Decker M.J.
        • Viola R.W.
        • O'Connor D.D.
        • Steadman J.R.
        Intra-articular knee joint effusion induces quadriceps avoidance gait patterns.
        Clin Biomech (Bristol, Avon). 2000; 15: 147-159
        • Cheing G.L.
        • Hui-Chan C.W.
        • Chan K.M.
        Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain?.
        Clin Rehabil. 2002; 16: 749-760
        • Lee K.H.
        • Chung J.M.
        • Willis Jr., W.D.
        Inhibition of primate spinothalamic tract cells by TENS.
        J Neurosurg. 1985; 62: 276-287
        • Lundberg A.
        • Malmgren K.
        • Schomburg E.D.
        Cutaneous facilitation of transmission in reflex pathways from Ib afferents to motoneurones.
        J Physiol. 1977; 265: 763-780
        • Pietrosimone B.G.
        • Hart J.M.
        • Saliba S.A.
        • Hertel J.
        • Ingersoll C.D.
        Immediate effects of transcutaneous electrical nerve stimulation and focal knee joint cooling on quadriceps activation.
        Med Sci Sports Exerc. 2009; 41: 1175-1181
        • Pietrosimone B.G.
        • Saliba S.A.
        • Hart J.M.
        • Hertel J.
        • Kerrigan D.C.
        • Ingersoll C.D.
        Effects of transcutaneous electrical nerve stimulation and therapeutic exercise on quadriceps activation in people with tibiofemoral osteoarthritis.
        J Orthop Sports Phys Ther. 2011; 41: 4-12
        • Øiestad B.
        • Quinn E.
        • Nevitt M.
        • Lewis C.
        • Torner J.
        • Felson D.
        Modifiable predictors of functional decline over 7 years in people with symptomatic knee osteoarthritis: data from the multicenter osteoarthritis study.
        Osteoarthritis Cartilage. 2015; 23: A173
        • Lewek M.
        • Rudolph K.
        • Axe M.
        • Snyder-Mackler L.
        The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction.
        Clin Biomech (Bristol, Avon). 2002; 17: 56-63
        • Perry J.
        Gait analysis: normal and pathological function.
        Slack Inc, Thorofare1992: 89-108
        • Jefferson R.J.
        • Collins J.J.
        • Whittle M.W.
        • Radin E.L.
        • O'Connor J.J.
        The role of the quadriceps in controlling impulsive forces around heel strike.
        Proc Inst Mech Eng H. 1990; 204: 21-28
        • Hurley M.V.
        The role of muscle weakness in the pathogenesis of osteoarthritis.
        Rheum Dis Clin North Am. 1999; 25: 283-298
        • Segal N.A.
        • Glass N.A.
        • Torner J.
        • et al.
        Quadriceps weakness predicts risk for knee joint space narrowing in women in the MOST cohort.
        Osteoarthritis Cartilage. 2010; 18: 769-775
        • Otterness I.G.
        • Weiner E.
        • Swindell A.C.
        • Zimmerer R.O.
        • Ionescu M.
        • Poole A.R.
        An analysis of 14 molecular markers for monitoring osteoarthritis: relationship of the markers to clinical end-points.
        Osteoarthritis Cartilage. 2001; 9: 224-231
        • Perry J.
        • Antonelli D.
        • Ford W.
        Analysis of knee-joint forces during flexed-knee stance.
        J Bone Joint Surg Am. 1975; 57: 961-967
        • Hungerford D.S.
        • Lennox D.W.
        Rehabilitation of the knee in disorders of the patellofemoral joint: relevant biomechanics.
        Orthop Clin North Am. 1983; 14: 397-402
        • Iles J.F.
        Evidence for cutaneous and corticospinal modulation of presynaptic inhibition of Ia afferents from the human lower limb.
        J Physiol. 1996; 491: 197-207
        • Hurwitz D.E.
        • Ryals A.R.
        • Block J.A.
        • Sharma L.
        • Schnitzer T.J.
        • Andriacchi T.P.
        Knee pain and joint loading in subjects with osteoarthritis of the knee.
        J Orthop Res. 2000; 18: 572-579
        • Maserejian N.N.
        • Fischer M.A.
        • Trachtenberg F.L.
        • et al.
        Variations among primary care physicians in exercise advice, imaging, and analgesics for musculoskeletal pain: results from a factorial experiment.
        Arthritis Care Res. 2014; 66: 147-156
        • McAlindon T.E.
        • Bannuru R.R.
        • Sullivan M.C.
        • et al.
        OARSI guidelines for the non-surgical management of knee osteoarthritis.
        Osteoarthritis Cartilage. 2014; 22: 363-388