Levin MF, Tekeoğlu Y, Maher CG
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Epidemiology of spasticity following traumatic spinal cord injury.

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Journal Archives of physical medicine and rehabilitation
Year 1990
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Two epidemiologic studies of spasticity at discharge and first annual follow-up in patients with traumatic spinal cord injury (SCI) are reported. Study 1 analyzed occurrence of spasticity and its severity for 96 subjects at one SCI center, with 67% of subjects developing spasticity by discharge and 37% receiving antispasticity medication. By follow-up, these figures were 78% and 49%, respectively. Incidence of spasticity was higher among cervical and upper thoracic than lower thoracic and lumbosacral levels of injury groups (p less than 0.001). Study 2 analyzed presence of spasticity severe enough to have warranted treatment on 466 subjects at 13 collaborating SCI centers, where 26% of subjects received treatment by discharge and 46% by follow-up. Probability of spasticity treatment was significantly related (p less than 0.05) to days from injury to discharge and level of injury group, whereas age, gender, and Frankel grade were not related. Among only cervical and upper thoracic subjects, Frankel grade was significantly related (p less than 0.01), with grades A (27%) and D (29%) being less frequently treated than grades B (50%) and C (52%). Importance of controlling the above significantly related factors is emphasized for future studies of methods to reduce incidence or severity of spasticity.

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Relief of hemiparetic spasticity by TENS is associated with improvement in reflex and voluntary motor functions.

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Authors Levin MF , Hui-Chan CW
Journal Electroencephalography and clinical neurophysiology
Year 1992
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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Our previous studies showed that a single 45 min application of transcutaneous electrical nerve stimulation (TENS) prolonged soleus H and stretch reflex latencies in hemiparetic subjects. In addition, 9 daily 30 min TENS applications enhanced vibratory inhibition of the H reflex and tended to decrease hyperactive stretch reflexes. These findings suggested that longer-term TENS may be effective in reducing hemiparetic spasticity. Our present objectives were 2-fold: to determine whether longer-term repetitive TENS stimulation would lead to a reduction in clinical spasticity in hemiparetic subjects, and whether such a reduction could be associated with a decrease in stretch reflex excitability and an improvement in voluntary motor function. We compared the effects of 15 daily 60 min TENS treatments over a 3 week period, with those of placebo stimulation applied to the common peroneal nerve of the affected leg in similar groups of spastic hemiparetic subjects. Our test battery consisted of 5 measurements which assessed (1) clinical spasticity scores, (2) maximal H reflex to M response ratios, (3) vibratory inhibition of H reflex, (4) stretch reflexes, and (5) maximal voluntary isometric plantarflexion and dorsiflexion, in standing. In contrast to placebo stimulation which produced no significant effects, repeated applications of TENS over time decreased clinical spasticity (P less than 0.05), and increased vibratory inhibition of the soleus H reflex (P = 0.02) after 2 weeks. These changes occurred with a substantial improvement in voluntary dorsiflexing force up to 820%, but not plantarflexing force. They were followed by a reduction in the magnitude of stretch reflexes (P = 0.05) in the spastic ankle plantarflexor, concomitant with a decrease in the EMG co-contraction ratios after a further week of stimulation. Our results thus indicated that repeated applications of TENS can reduce clinical spasticity and improve control of reflex and motor functions in hemiparetic subjects. Furthermore, the underlying mechanisms may be due partly to an enhancement in presynaptic inhibition of the spastic plantarflexor, and partly to a possible "disinhibition" of descending voluntary commands to the paretic dorsiflexor motoneurons.

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Stretch reflex latencies in spastic hemiparetic subjects are prolonged after transcutaneous electrical nerve stimulation.

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Authors Hui-Chan CW , Levin MF
Journal The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques
Year 1993
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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Low-intensity repetitive electrical stimulation such as dorsal column and transcutaneous electrical nerve stimulation (TENS) reportedly decreases spasticity and improves voluntary motor control. However, the mechanisms mediating these effects are unclear. Recent findings suggest that spasticity may be characterized more appropriately by a decrease in the stretch reflex threshold than by an increase in gain. Our objectives were: (1) to examine possible changes in stretch reflex excitability following 45 min of TENS, (2) to map out the time course of possible post-stimulation effects via both latency and magnitude (amplitude or area) measurements, and (3) to determine the role of segmental versus non-segmental mechanisms involved in mediating these changes. The effects of 45 min of segmentally and heterosegmentally applied TENS on lower limb reflexes in ten spastic hemiparetic subjects were contrasted with those resulting from placebo stimulation. We found that both segmentally and heterosegmentally applied TENS caused an immediate increase in soleus H reflex latencies that was evident for up to 60 minutes post-stimulation in over 75% of the subjects. Similar increases for up to 60 and 40 minutes post-stimulation was noted for the stretch reflex latencies in 50% and 67% of the subjects respectively for segmental and heterosegmental stimulation. These results suggested that manipulation of segmental and heterosegmental afferents for 45 min may lead to a decrease of the otherwise augmented stretch reflex excitability accompanying hemiparetic spasticity.

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Effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in patients with hemiplegia.

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Journal Scandinavian journal of rehabilitation medicine
Year 1995
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The effect of afferent cutaneous electrical stimulation on the spasticity of leg muscles was studied in 20 patients with chronic hemiplegia after stroke. Stimulation electrodes were placed over the sural nerve of the affected limb. The standard method of cutaneous stimulation, TENS with impulse frequency of 100 Hz, was applied. The tonus of the leg muscles was measured by means of an electrohydraulic measuring brace. The EMG stretch reflex activity of the tibialis anterior and triceps surae muscles was detected by surface electrodes and recorded simultaneously with the measured biomechanical parameters. In 18 out of 20 patients, a mild but statistically significant decrease in resistive torques at all frequencies of passive ankle movements was recorded following 20 min of TENS application. The decrease in resistive torque was often (but not always) accompanied by a decrease in reflex EMG activity. This effect of TENS persisted up to 45 min after the end of TENS. The results of the study support the hypothesis that TENS applied to the sural nerve may induce short-term post-stimulation inhibitory effects on the abnormally enhanced stretch reflex activity in spasticity of cerebral origin.

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Effect of transcutaneous electrical nerve stimulation (TENS) on Barthel Activities of Daily Living (ADL) Index score following stroke.

Authors Tekeoğlu Y , Adak B , Göksoy T
Journal Clinical rehabilitation
Year 1998
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This article is included in 6 Systematic reviews Systematic reviews (6 references)

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OBJECTIVE: To evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) and placebo TENS on the level of activities of daily living (ADL) of stroke patients. SETTING: A university hospital. PATIENTS: Patients who had had a stroke 30-240 days before entry to a university rehabilitation centre. DESIGN: Controlled design with block randomization and blinded assessment. Intervention: All patients had Todd-Davies exercises. In group 1 (n = 30) TENS with frequency of 100 Hz was used at an intensity that the patient could tolerate; in group 2 (n = 30) patients were given placebo TENS. The treatment protocol consisted of 40 sessions (eight weeks). Outcomes: The Barthel Index for daily living activities was used to measure functional changes over time, and the Ashworth Scale was used to measure spasticity in the elbow, knee and ankle. These measurements were made prior to and following the treatment by assessors unaware of the patient's group allocation. RESULTS: There were 30 patients in each group. Patients in group 1 (active TENS) were more disabled at entry to the study. Statistically significant improvements were recorded in all parameters such as feeding, transfer, hygiene, toileting, bathing, walking, climbing stairs, dressing, bowel and bladder care for group 1 (p<0.001) but only in some items in group 2. The change in total score was significant in both groups but the difference in the change score between the two groups was statistically significant (p<0.001). Spasticity was reduced in the active treatment group. CONCLUSION: TENS appears to be an effective adjunct in the regaining of motor functions and improving ADL in hemiplegic patients, but the accidental imbalance in severity of disability at entry makes interpretation uncertain.

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The effects of electrical nerve stimulation of the lower extremity on H-reflex and F-wave parameters.

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Authors Joodaki MR , Olyaei GR , Bagheri H
Journal Electromyography and clinical neurophysiology
Year 2001
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The main purpose of this study was to investigate the effects of electrical nerve stimulation on alpha motoneurons excitability. The electrophysiological parameters of H-reflex and F-wave were assessed for this object. These experiments was performed on ten non-athletic healthy men without neurologic disorders with mean age 25.6 years (SD 4.4) and three spastic hemiplegic patients with mean age 65.33 years (SD 6.32). In the experimental protocol, electrical stimulation (TENS) applied on common peroneal nerve with frequency 99 Hz and duration 0.25 ms for 30 minutes. H-reflex and F-wave of the soleus muscle were recorded in three stages sequenced immediately, 5 minutes and 10 minutes later on. The parameters such as amplitudes and latencies of H-reflex and F-wave were compared with the data of first record before stimulation. Finally, after 30 minutes application of TENS the following results were obtained: 1. The mean peak to peak amplitude of H-reflexes and F-waves were significantly decreased after application of TENS in normal subjects. (P < 0.05) 2. H/M ratios and F/M ratios were significantly decreased after application of TENS in normal subjects. (P < 0.05) 3. The mean latency of H-reflexes and F-waves were significantly increased after application of TENS in normal subjects. (P < 0.05) 4. In spastic patients, the mean peak to peak amplitude of H-reflexes and F-waves, H/M and F/M ratios were significantly decreased and the mean latencies of H-reflexes and F-waves were significantly increased after application of TENS. The reduction of amplitude of H-reflexes and F-waves, H/M and F/M ratios demonstrated reduction of spasticity in patients group. The above-mentioned parameters are parts of electrophysiological indicators about assessment of spasticity.

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Reliability of the PEDro Scale for rating quality of randomized controlled trials.

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Journal Physical Therapy
Year 2003
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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BACKGROUND AND PURPOSE: Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. METHOD: In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). RESULTS: The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was.56 (95% confidence interval=.47-.65) for ratings by individuals, and the ICC for consensus ratings was.68 (95% confidence interval=.57-.76). DISCUSSION AND CONCLUSION: The reliability of ratings of PEDro scale items varied from 'fair' to 'substantial,' and the reliability of the total PEDro score was 'fair' to 'good.'

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Spasticity after stroke: its occurrence and association with motor impairments and activity limitations.

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Journal Stroke
Year 2004
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BACKGROUND AND PURPOSE: There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations). METHODS: Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index. RESULTS: Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients. CONCLUSIONS: Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient's disabilities is essential before a decision is made on the most proper rehabilitation approach.

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Prevalence and treatment of spasticity reported by multiple sclerosis patients.

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Journal Multiple sclerosis (Houndmills, Basingstoke, England)
Year 2004
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The objective of this study was to characterize the population of multiple sclerosis (MS) patients suffering from spasticity and to evaluate treatment patterns, including intrathecal baclofen (ITB) delivery, related to patient quality of life (QOL). We conducted a cross-sectional, two-level study using data from the Patient Registry of the North American Research Committee on MS (NARCOMS). In addition, we surveyed a subgroup of 198 preselected patients who are using ITB (ITBG) and a random sample of 315 oral drug users (ORALG). Among the registrants, 16% reported no spasticity, 31% minimal, 19% mild, 17% moderate (frequently affects activities), 13% severe (daily forced to modify activities) and 4% total (prevents daily activities). Patients experiencing greater severity included by proportion males, and those older and with longer duration of MS. QOL scores decreased inversely with severity. In the focused survey, ITBG reported lower levels of spasticity than ORALG, less stiffness in the legs, less pain and fewer spasms at any time. They scored significantly lower in the SF-36 physical component, yet reported less fatigue on the MFIS scale. Prevalence data reveal that one third of MS patients modify or eliminate daily activities as a result of spasticity. Treatment of spasticity can significantly impact QOL parameters by reducing spasms, pain and fatigue.

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Effects of surface electrical stimulation on the muscle-tendon junction of spastic gastrocnemius in stroke patients.

Journal Disability and rehabilitation
Year 2005
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PURPOSE: The purpose of this study was to explore the effects of spasticity suppression by surface electrical stimulation (ES) on the muscle-tendon junction of spastic gastrocnemius muscles in stroke.METHODS: Twenty-four neurologically stable stroke patients (aged 41-69 years, 12-35 months post-stroke), with spasticity graded 2 or 3 on the modified Ashworth scale, were recruited and divided into two groups. In the ES group, each patient received 20 min of surface ES once daily, 6 days per week for 1 month. In the control group, ES was used with stimulation intensity kept at zero. To evaluate the therapeutic effect, the modified Ashworth scale, Finax/Mmax ratio, H-reflex latency, H-reflex recovery curve, and the 10-m walking time were tested before and after the 1-month treatment.RESULTS: In the ES group, the modified Ashworth Scale showed a trend toward reduced spasticity after 1 month of treatment. The Fmax/Mmax ratio decreased from 8.10% +/- 4.84% to 4.00% +/- 1.36%; the H-reflex latency increased from 28.87 +/- 2.45 ms to 29.40 +/- 2.57 ms; the H-reflex recovery curves indicated a downward shift; and the 10-metre walking time significantly decreased after ES. In the control group, none of the measures showed a statistically significant change. CONCLUSIONS: In the study, we demonstrated a way to suppress spasticity at a metameric site and to increase walking speed effectively by applying surface ES on the muscle-tendon junction of spastic gastrocnemius muscles.

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Transcutaneous electrical nerve stimulation versus baclofen in spasticity: clinical and electrophysiologic comparison.

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Journal American journal of physical medicine & rehabilitation
Year 2005
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OBJECTIVES: Clinical and electrophysiologic comparison of the efficacy of transcutaneous electrical nerve stimulation (TENS) and oral baclofen in the treatment of spasticity. DESIGN: Patients with spinal cord injury and spasticity were included in the study. Ten patients were assigned to oral baclofen and 11 to TENS groups. For the comparison of H-reflex variables, 20 healthy individuals were allocated to a control group. TENS was applied to the tibial nerve for 15 days at a frequency of 100 Hz. Clinical (spasm frequency scale, painful spasm scale, lower limb Ashworth score, clonus score, deep tendon reflex score, plantar stimulation response score) and electrophysiologic evaluations (H-reflex response at the highest amplitude, latency of maximum H-reflex, and ratio of H-reflex response at the highest amplitude to M response at maximum amplitude) of the lower limb and functional evaluations (functional disability score and FIM) were carried out in baclofen and TENS groups before and after treatment. Posttreatment evaluation was made 24 hrs after the 15th session in the TENS group. In addition, clinical spasticity scores and electrophysiologic variables were measured 15 mins after the first application and 15 mins after the 15th session. RESULTS: Significant improvement was detected in lower limb Ashworth score, spasm frequency scale, deep tendon reflex score, functional disability score, and FIM in the baclofen (P = 0.011, P = 0.014, P = 0.025, P = 0.004, and P = 0.005, respectively) and TENS (P = 0.020, P = 0.014, P = 0.025, P = 0.003, and P = 0.003, respectively) group after treatment. Decrease in H-reflex maximum amplitude was significant in the TENS group (P = 0.026). Most marked improvement was observed in the third evaluation, 15 mins after the 15th session, particularly in lower limb Ashworth score (P = 0.006) and H-reflex maximum amplitude (P = 0.006) in the TENS group. The percentage change in clinical, electrophysiologic, and functional variables caused by baclofen was not different from that caused by repeated applications of TENS in the short- and long-term evaluations (P > 0.05). CONCLUSION: TENS may be recommended as a supplement to medical treatment in the management of spasticity.

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Transcutaneous electrical nerve stimulation combined with task-related training improves lower limb functions in subjects with chronic stroke.

Authors Ng SS , Hui-Chan CW
Journal Stroke; a journal of cerebral circulation
Year 2007
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BACKGROUND AND PURPOSE: Previous studies have shown that repeated sensory inputs could enhance brain plasticity and cortical motor output. The purpose of this study was to investigate whether combining electrically induced sensory inputs through transcutaneous electrical nerve stimulation (TENS) with task-related training (TRT) in a home-based program would augment voluntary motor output in chronic stroke survivors better than either treatment alone or no treatment. METHODS: Eighty-eight patients with stroke were assigned randomly to receive a home-based program of (1) TENS, (2) TENS+TRT, (3) placebo TENS+TRT, or (4) no treatment (control) 5 days a week for 4 weeks. Outcome measurements included Composite Spasticity Scale, peak torques generated during maximum isometric voluntary contraction of ankle dorsiflexors and plantarflexors, and gait velocity recorded at baseline, after 2 and 4 weeks of treatment, and 4 weeks after treatment ended. RESULTS: When compared with TENS, the combined TENS+TRT group showed significantly greater improvement in ankle dorsiflexion torque at follow-up and in ankle plantarflexion torque at week 2 and follow-up (P<0.01). When compared with placebo+TRT, the TENS+TRT group produced earlier and greater reduction of plantarflexor spasticity and improvement in ankle dorsiflexion torque at week 2 (P<0.01). When compared with all 3 groups, the TENS+TRT group showed significantly greater improvement in gait velocity (P<0.01). CONCLUSIONS: In patients with chronic stroke, 20 sessions of a combined TENS+TRT home-based program decreased plantarflexor spasticity, improved dorsiflexor and plantarflexor strength, and increased gait velocity significantly more than TENS alone, placebo+TRT, or no treatment. Such improvements can even be maintained 4 weeks after treatment ended.

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The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis.

Authors Miller L , Mattison P , Paul L , Wood L
Journal Multiple sclerosis (Houndmills, Basingstoke, England)
Year 2007
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Spasticity is a common and often disabling symptom associated with multiple sclerosis (MS). Transcutaneous electrical nerve stimulation (TENS) has been found effective in reducing spasticity in conditions such as stroke, but there is little evidence to support its use in MS. The aim of this study was to evaluate the effectiveness of TENS on spasticity in MS and, furthermore, to compare two different application times. Thirty-two subjects were randomized into two groups, and a single, blind, crossover design was used to compare two weeks of 60 minutes and 8 hours daily of TENS applications (100 Hz and 0.125 ms pulse width). Outcomes were examined using the Global Spasticity Score (GSS), the Penn Spasm Score (PSS), and a visual analogue scale (VAS) for pain. The results of the study demonstrated that there were no statistically significant differences in the GSS following either 60 minutes or 8 hours daily of TENS (P=0.433 and 0.217, respectively). The 8-hour application time led to a significant reduction in muscle spasm (P=0.038) and pain (P = 0.008). Thus, this study suggests that, whilst TENS does not appear to be effective in reducing spasticity, longer applications may be useful in treating MS patients with pain and muscle spasm.

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Immediate effect of transcutaneous electrical nerve stimulation on spasticity in patients with spinal cord injury.

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Journal Clinical rehabilitation
Year 2010
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OBJECTIVE: To investigate the immediate effect of transcutaneous electrical nerve stimulation (TENS) on spasticity in patients with spinal cord injury. DESIGN: Randomized controlled trial. SETTING: Extended rehabilitation centre. SUBJECTS AND INTERVENTION: Eighteen subjects with spinal cord injury and symptoms of spasticity over lower limbs were randomly assigned to receive either 60 minutes of active TENS (0.25 ms, 100 Hz, 15 mA) or 60 minutes of placebo non-electrically stimulated TENS over the common peroneal nerve. OUTCOME MEASURES: Composite Spasticity Score was used to assess the spasticity level of ankle plantar flexors immediately before and after TENS application. Composite Spasticity Score consisted of Achilles tendon jerks, resistance to full-range passive ankle dorsiflexion and ankle clonus. Between-group statistical differences of reduction of Composite Spasticity Score, Achilles tendon jerks, resistance to full-range passive ankle dorsiflexion and ankle clonus were calculated using the Mann-Whitney test. Within-group statistical differences of Composite Spasticity Score, Achilles tendon jerks, resistance to full-range passive ankle dorsiflexion and ankle clonus were calculated using the Wilcoxon signed ranks test. RESULTS: Significant reductions were shown in Composite Spasticity Score by 29.5% (p = 0.017), resistance to full-range passive ankle dorsiflexion by 31.0% (p = 0.024) and ankle clonus by 29.6% (p = 0.023) in the TENS group but these reductions were not found in the placebo TENS group. The between-group differences of both Composite Spasticity Score and resistance to full-range passive ankle dorsiflexion were significant (p = 0.027 and p = 0.024, respectively). CONCLUSION: This study showed that a single session of TENS could immediately reduce spasticity.

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Immediate effects of TENS and cryotherapy in the reflex excitability and voluntary activity in hemiparetic subjects: a randomized crossover trial.

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Journal Revista brasileira de fisioterapia (Sao Carlos (Sao Paulo, Brazil))
Year 2012
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BACKGROUND: The disorder of reflex and motor function in patients affected by stroke causes negative impact on the performance of movement patterns and affects the functional activities. OBJECTIVES: To investigate the immediate effects of transcutaneous electrical nerve stimulation (TENS) and cryotherapy interventions on the spinal reflex excitability and in the voluntary electromyography (EMG) activity in people with chronic stroke. METHOD: Randomized crossover trial. The maximum H-reflex (Hmax), the H-reflex latency and the maximum motor response (Mmax) of the soleus muscle and also the EMG of the tibialis muscle where evaluated before and after the application of TENS, cryotherapy and control conditions. RESULTS: The Hmax/Mmax ratio was statistically significant higher (p=0.0245) and the H-reflex latency was statistically significant lower (p=0.0375) in the soleus muscle of the affected limb. The EMG amplitude of the tibialis anterior was reduced in the compromised limb (p&lt;0.0001). After the use of the TENS, a reduction in the Hmax/Mmax ratio (p=0.0006) was observed leading to lower reflex excitability. However, after the cryotherapy intervention an increase of the Hmax/Mmax ratio was observed, which was accompanied by an increase in the H-reflex latency (p=0.0001). The EMG amplitude has not changed by any of the interventions. CONCLUSIONS: Our findings suggest that TENS may be a choice for immediate reduction of reflex excitability, whereas cryotherapy intervention may increase reflex excitability in hemiparetic subjects. However, none of the changes mediated by either intervention were able to modify the electrical activity in the antagonist muscle of the spastic muscle. This trial was registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12610000302055.

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[Evaluation and quantification of spasticity: a review of the clinical, biomechanical and neurophysiological methods].

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Journal Revista de neurologia
Year 2012
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INTRODUCTION: Spasticity is a sensory-motor disorder that affects about 85% of the patients with multiple sclerosis and between 65-78% of those with spinal cord injury, among other neurological conditions. Although hypertonia is generally easy to recognise clinically, quantifying it is quite a complex matter. The large number of clinical scales that exist and their subjectivity, the discrepancy between the spasticity perceived by the patient and the clinical measurement, as well as the lack of a general correlation between the neurophysiological measures and hypertonia, all make it especially difficult, in methodological terms, to perform a valid, reliable measurement of the degree of spasticity presented by the patient. AIMS: To review the main methods of evaluating spasticity published in the scientific literature and to carry out a description and critical analysis of their advantages, shortcomings and metric properties in patients with a neurological pathology. DEVELOPMENT: The different methods described for evaluating spasticity are reviewed and classified in three broad groups, namely, clinical scales specifically designed for such a purpose, biomechanical tests and neurophysiological methods. CONCLUSIONS: There is little agreement on the definition of spasticity and the need for the evaluators' training and experience when it comes to evaluating it. We recommend using a combination of the different evaluation instruments, such as the scales, biomechanical methods and neurophysiological measures reported in this study, to carry out a general diagnosis of the degree of spasticity present in the patient.

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Comparison of the effect of baclofen and transcutaneous electrical nerve stimulation for the treatment of spasticity in multiple sclerosis.

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Journal Neurological research
Year 2013
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OBJECTIVE: The aim of this study was to compare the relative efficacy of baclofen and self-applied transcutaneous electrical nerve stimulation (TENS) for the treatment of spasticity in the lower extremities in multiple sclerosis (MS). METHODS: A randomized controlled clinical trial was conducted from September 2010 to June 2011. Fifty-two patients with MS presenting muscle spasm in the leg at 20-50 years of age were randomly allocated to receive a four-week treatment course of either baclofen (10 mg twice daily, increasing over three weeks to 25 mg) or self-applied TENS. Response to treatment was assessed at four weeks after commencement of the intervention by modified Ashworth scale (MAS). RESULTS: Spasticity decreased in both groups. Of the 26 people treated with TENS, the mean (standard deviation (SD)) MAS decreased from 1.77 (0.29) at baseline to 0.73 (0.70) at the four-week follow-up (P < 0.001). Correspondingly, in the 26 people treated with baclofen, the mean (SD) MAS decreased from 1.73 (0.38) to 1.15 (0.63) (P < 0.001). The mean difference in MAS score at the four-week follow-up was significantly lower in the TENS group than the baclofen group (mean difference -0.42; 95% CI, -0.79, -0.05; P < 0.05). DISCUSSION: This study demonstrates that both baclofen and TENS can be effective in reducing MS-related spasticity. The mean MAS score was significantly lower in the TENS group. However given the side-effect profile of baclofen, TENS may have some benefits over baclofen.

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The effects of transcutaneous electrical nerve stimulation on strength, proprioception, balance and mobility in people with stroke: a randomized controlled cross-over trial.

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Journal Clinical rehabilitation
Year 2013
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OBJECTIVE: To investigate the feasibility and potential efficacy of 'activeTENS' (that is transcutaneous electrical nerve stimulation (TENS) during everyday activities) by assessing the immediate effects on strength, proprioception, balance/falls risk and mobility after stroke. DESIGN: A paired-sample randomized cross-over trial. SUBJECTS: Twenty-nine mobile chronic stroke survivors with no pre-existing conditions limiting balance or mobility or contra-indications to TENS. SETTING: University clinical research facility. INTERVENTION: A single session of 'activeTENS' delivered via a 'sock electrode' (70-130 Hz, five second cycle) plus a session of control treatment (wearing the sock electrode with no stimulation), lasting approximately two hours in total. MAIN OUTCOMES: Dorsiflexor and plantarflexor strength and proprioception using an isokinetic dyanometer, balance and falls risk (Standing Forward Reach Test) and gait speed (10-m walk test). RESULTS: All participants tolerated 'active TENS'. Most parameters improved during stimulation with activeTENS; balance (p = 0.009), gait speed (p = 0.002), plantarflexor strength (p = 0.008) and proprioception of plantarflexion (p = 0.029), except dorsiflexor strength (p = 0.194) and dorsiflexion proprioception (p = 0.078). CONCLUSIONS: The results provide initial evidence of the potential of 'active TENS' to benefit physical function after stroke which warrants further phase II trials to develop the intervention. Concerns that stimulation could have a detrimental impact on balance and increase risk of falls were not supported.