Percutaneous Electrical Nerve Stimulation

Original Editor - Khloud Shreif

Top Contributors - Khloud Shreif, Kim Jackson and Lucinda hampton  

Introduction[edit | edit source]

Percutaneous nerve stimulation belongs to the field of neuromodulation. Neuromodulation:

  • Interferes at the neurological level and aims to alter nerve activity.
  • Works by either actively stimulating nerves to produce a natural biological response or by applying targeted pharmaceutical agents in tiny doses directly to site of action.
  • Neurostimulation devices involve the application of electrodes to the brain, the spinal cord or peripheral nerves.

Percutaneous Nerve Stimulation acts upon peripheral nerves, stimulating peripheral sensory nerves at the dermatome levels that correspond to the local pathology.

Mechanism Of Action[edit | edit source]

There are different action theories but the mechanism of action of PEMS is believed to be the same for TENS. The two main theories:

  1. Depends on (The Gate control theory) modulation of A-beta fibers. Percutaneous electrical nerve stimulation creates an electrical field that hyperpolarizes c-fibers preventing action potential propagation along the pain pathway of small diameter pain fibers at spinal cord level to inhibit pain transmission.
  2. Local release of biochemical mediators such as neurotransmitters and endorphins and encephalin hindering the response to pain[2] .
  3. At the level of cortical and subcortical structures it stimulates the descending pain modulatory pathway and increase in the cerebral blood flow to the anterior cingulate cortex, insular cortex, anteroventral insula, thalamus, and primary somatosensory cortex as demonstrated by positron emission tomography PET[3].

PENS usually applied in continuous biphasic waveform with a pulse duration ranging from 250 to 500 ms and low or high frequency [4]. There is a randomized trial stated that low and high frequency of PEMS with dry needling showed short term effect on pain intensity in patients with myofascial neck pain with no improvement in fear of movement[5].

Indications[edit | edit source]

  • For mixed and refractory pain for different clinical conditions[6].
  • May be used to reduce the perception of pain in several musculoskeletal diseases of including LBP, total knee arthroplasty, chronic pain after amputation, and opioid-resistant cancer pain and more studies about its effect for those who don't respond to pharmacological medicine are needed. It's long term effect on low back pain [7]still unclear yet.
  • Overactive bladder in children.
  • Unspecified chronic pain conditions.

Advantages[edit | edit source]

No complications or side effect such as itching after needle removal has been reported, just the feeling of discomfort during the needle removal or insertion, well-tolerated  for patients with neuropathic pain

Less interaction with different pharmacological drugs.

Used as a complementary treatment with pharmacological drugs, physical exercise, and instrumental rehabilitative techniques.

Clinical Application[edit | edit source]

  • Percutaneous tibial nerve stimulation

Percutaneous tibial nerve stimulation (the most known) is directed to the posterior tibial nerve and alters nerve activity in the pelvis via the plexus sacralis[1]. The posterior tibial nerve is derived from the lumbar-sacral nerves (L4-S3), which control the bladder detrusor, and are located near the ankle[8].

PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function. During PTNS treatment, the patient’s foot is comfortably elevated and supported. Also during treatment, a slim needle electrode is placed near the tibial nerve at the ankle. The device known is connected to the electrode and sends mild electrical pulses to the tibial nerve. These impulses travel to the sacral nerve plexus, the group of nerves at the base of the spine responsible for bladder function.

By stimulating these nerves through gentle electrical impulses, bladder activity can be changed. Because this change happens gradually, patients receive a series of 12-weekly, 30-minute treatments. After the 12 treatments, when the patient’s response to therapy is assessed, occasional treatments may be needed to sustain symptom improvement[9].

This therapeutic treatment is for patients experiencing overactive bladder symptoms (urinary urgency, urinary frequency and/or urge incontinence). PTNS has been approved by regulatory agencies outside the United States to treat fecal incontinence, but has not been approved for this usage in the US at this time. PTNS is generally used after behavior modifications, Kegel exercises and failure of medications.

Used for chronic pelvic pain. RCT show that when PTNS was used for 30-min/ session, weekly applied for 12 weeks: significant improvement in pain and quality of life was achieved at Week 12; improvement in the quality of life sustained for the PTNS group at six months[10]


  • Pudendal nerve stimulation With ultrasound guiding Pudendal nerve neuromodulation is used in cases with pudendal neuralgia, and used as an alternative method to treat Urinary Incontinence[12].
  • Sacral nerve roots stimulation
  • Occipital nerve field stimulation as in fibromyalgia[3]

References[edit | edit source]

  1. 1.0 1.1 Needling Org. Percutaneous nerve stimulation. Available: (accessed 1.11.2021)
  2. Lin T, Gargya A, Singh H, Sivanesan E, Gulati A. Mechanism of peripheral nerve stimulation in chronic pain. Pain Medicine. 2020 Aug;21(Supplement_1):S6-12.
  3. 3.0 3.1 Strand NH, D’Souza R, Wie C, Covington S, Maita M, Freeman J, Maloney J. Mechanism of Action of Peripheral Nerve Stimulation. Current Pain and Headache Reports. 2021 Jul;25(7):1-9.
  4. Plaza‐Manzano G, Gómez‐Chiguano GF, Cleland JA, Arías‐Buría JL, Fernández‐de‐las‐Peñas C, Navarro‐Santana MJ. Effectiveness of percutaneous electrical nerve stimulation for musculoskeletal pain: A systematic review and meta‐analysis. European Journal of Pain. 2020 Jul;24(6):1023-44.
  5. Fernández-Carnero J. Effectiveness of Dry Needling with Percutaneous Electrical Nerve Stimulation of High Frequency Versus Low Frequency in Patients with Myofascial Neck Pain. Pain physician. 2021 Mar;24:135-43.
  6. de Sire A, Ammendolia A, Lippi L, Farì G, Cisari C, Invernizzi M. Percutaneous Electrical Nerve Stimulation (PENS) as a Rehabilitation Approach for Reducing Mixed Chronic Pain in Patients with Musculoskeletal Disorders. Applied Sciences. 2021 Jan;11(9):4257.
  7. Ghoname ES, Craig WF, White PF, Ahmed HE, Hamza MA, Henderson BN, Gajraj NM, Huber PJ, Gatchel RJ. Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study. Jama. 1999 Mar 1;281(9):818-23.
  8. Tam J, Loeb C, Grajower D, Kim J, Weissbart S. Neuromodulation for chronic pelvic pain. Current urology reports. 2018 May;19(5):1-9.
  9. The Simon Foundation for Continence Percutaneous Tibial Nerve Stimulation (PTNS) Available: 1.11.2021)
  10. Istek A, Ugurlucan FG, Yasa C, Gokyildiz S, Yalcin O. Randomized trial of long-term effects of percutaneous tibial nerve stimulation on chronic pelvic pain. Archives of gynecology and obstetrics. 2014 Aug;290(2):291-8.
  11. The Oregon Clinic. What is Percutaneous Tibial Nerve Stimulation (PTNS). Available from: [last accessed 23/10/2021]
  12. Deng K, Balog BM, Lin DL, Hanzlicek B, Song QX, Zhu H, Damaser MS. Daily bilateral pudendal nerve electrical stimulation improves recovery from stress urinary incontinence. Interface focus. 2019 Aug 6;9(4):20190020.