Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis

Published:November 16, 2018DOI:



      (1) To determine the effect of transcutaneous electrical nerve stimulation (TENS) on poststroke spasticity. (2) To determine the effect of different parameters (intensity, frequency, duration) of TENS on spasticity reduction in adults with stroke. (3) To determine the influence of time since stroke on the effectiveness of TENS on spasticity.

      Data Sources

      PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to March 2017.

      Study Selection

      Randomized controlled trial (RCT), quasi-RCT, and non-RCT were included if (1) they evaluated the effects of TENS for the management of spasticity in participants with acute or subacute or chronic stroke using clinical and neurophysiological tools; and (2) TENS was delivered either alone or as an adjunct to other treatments.

      Data Extraction

      Two authors independently screened and extracted data from 15 of the 829 studies retrieved through the search using a pilot tested pro forma. Disagreements were resolved through discussion with other authors. Quality of studies was assessed using Cochrane risk of bias criteria.

      Data Synthesis

      Meta-analysis was performed using a random-effects model that showed (1) TENS along with other physical therapy treatments was more effective in reducing spasticity in the lower limbs compared to placebo TENS (SMD −0.64; 95% confidence interval [95% CI], −0.98 to −0.31; P=.0001; I2=17%); and (2) TENS, when administered along with other physical therapy treatments, was effective in reducing spasticity when compared to other physical therapy interventions alone (SMD −0.83; 95% CI, −1.51 to −0.15; P=.02; I2=27%). There were limited studies to evaluate the effectiveness of TENS for upper limb spasticity.


      There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors (review protocol registered at PROSPERO: CRD42015020151).


      List of abbreviations:

      95% CI (95% confidence interval), EMG (electromyogram), RCT (randomized controlled trial), SMD (standardized mean difference), TENS (transcutaneous electrical nerve stimulation)
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        • Zorowitz R.D.
        • Gillard P.J.
        • Brainin M.
        Poststroke spasticity.
        Neurology. 2013; 80: S45-S52
        • Wissel J.
        • Manack A.
        • Brainin M.
        Toward an epidemiology of poststroke spasticity.
        Neurology. 2013; 80: S13-S19
        • Watkins C.L.
        • Leathley M.J.
        • Gregson J.M.
        • Smith T.L.
        • Moore A.P.
        Prevalence of spasticity post stroke.
        Clin Rehabil. 2002; 16: 515-522
        • Doan Q.V.
        • Brashear A.
        • Gillard P.J.
        • et al.
        Relationship between disability and health-related quality of life and caregiver burden in patients with upper limb poststroke spasticity.
        PM R. 2012; 4: 4-10
        • Lundström E.
        • Smits A.
        • Borg J.
        • Terént A.
        Four-fold increase in direct costs of stroke survivors with without spasticity the first year after the event.
        Stroke. 2010; 41: 319-324
        • Winstein C.J.
        • Stein J.
        • Arena R.
        • et al.
        Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2016; 47: e98-e169
        • Thibaut A.
        • Laureys S.
        • Gosseries O.
        • Chatelle C.
        • Ziegler E.
        Spasticity after stroke: physiology, assessment and treatment.
        Brain Inj. 2013; 9052: 1-13
        • Richardson D.
        Physical therapy in spasticity.
        Eur J Neurol. 2002; 9: 17-22
        • Malas B.
        • Kacen M.
        Orthotic management in patients with stroke.
        Top Stroke Rehabil. 2001; 7: 38-45
        • Lehmann J.F.
        • Esselman P.C.
        • Ko M.J.
        • Smith J.C.
        • deLateur B.J.
        • Dralle A.J.
        Plastic ankle-foot orthoses: evaluation of function.
        Arch Phys Med Rehabil. 1983; 64: 402-407
        • Barnes M.P.
        Medical management of spasticity in stroke.
        Age Ageing. 2001; 30: 13-16
        • Kocabas H.
        Comparison of phenol and alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle for treatment of spastic foot after stroke: a randomized controlled pilot study.
        Eur J Phys Rehabil Med. 2010; 46: 5-10
        • Fukuhara T.
        • Kamata I.
        Selective posterior rhizotomy for painful spasticity in the lower limbs of hemiplegic patients after stroke: report of two cases.
        Neurosurgery. 2004; 54: 1268-1273
        • Sheean G.
        • McGuire J.R.
        Spastic hypertonia and movement disorders: pathophysiology, clinical presentation, and quantification.
        PM R. 2009; 1: 827-833
        • Martins F.L.
        • Carvalho L.C.
        • Silva C.C.
        • Brasileiro J.S.
        • Souza T.O.
        • Lindquist A.R.
        Immediate effects of TENS and cryotherapy in the reflex excitability and voluntary activity in hemiparetic subjects: a randomized crossover trial.
        Rev Bras Fisioter. 2012; 16: 337-344
        • Kim T.H.
        • In T.S.
        • Cho H.
        Task-related training combined with transcutaneous electrical nerve stimulation promotes upper limb functions in patients with chronic stroke.
        Tohoku J Exp Med. 2013; 231: 93-100
        • Tinazzi M.
        • Zarattini S.
        • Valeriani M.
        • et al.
        Long-lasting modulation of human motor cortex following prolonged transcutaneous electrical nerve stimulation (TENS) of forearm muscles: evidence of reciprocal inhibition and facilitation.
        Exp Brain Res. 2005; 161: 457-464
        • Yan T.
        • Hui-Chan C.W.
        Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: a randomized controlled trial.
        J Rehabil Med. 2009; 41: 312-316
        • Tekeoğlu Y.
        • Adak B.
        • Göksoy T.
        Effect of transcutaneous electrical nerve stimulation (TENS) on Barthel activities of daily living (ADL) index score following stroke.
        Clin Rehabil. 1998; 12: 277-280
        • Sonde L.
        • Kalimo H.
        • Viitanen M.
        Stimulation with high-frequency TENS -- effects on lower limb spasticity after stroke.
        Adv Physiother. 2000; 2: 183-187
        • Jung K.-S.
        • In T.-S.
        • Cho H.
        Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: a randomized controlled study.
        Gait Posture. 2017; 54: 183-187
        • Picelli A.
        • Dambruoso F.
        • Bronzato M.
        • et al.
        Efficacy of therapeutic ultrasound and transcutaneous electrical nerve stimulation compared with botulinum toxin type A in the treatment of spastic equinus in adults with chronic stroke: a pilot randomized controlled trial.
        Top Stroke Rehabil. 2014; 21: S8-S16
        • Sonde L.
        • Gip C.
        • Fernaeus S.E.
        • Nilsson C.G.
        • Viitanen M.
        Stimulation with low frequency (1.7 Hz) transcutaneous electric nerve stimulation (low-tens) increases motor function of the post-stroke paretic arm.
        Scand J Rehabil Med. 1998; 30: 95-99
        • Branco Mills P.
        • Dossa F.
        Transcutaneous electrical nerve stimulation for management of limb spasticity.
        Am J Phys Med Rehabil. 2016; 95: 309-318
        • Lin S.
        • Sun Q.
        • Wang H.
        • Xie G.
        Influence of transcutaneous electrical nerve stimulation on spasticity, balance, and walking speed in stroke patients: a systematic review and meta-analysis.
        J Rehabil Med. 2018; 50: 3-7
        • Ng S.S.
        • Hui-Chan C.W.
        Transcutaneous electrical nerve stimulation combined with task-related training improves lower limb functions in subjects with chronic stroke.
        Stroke. 2007; 38: 2953-2959
        • Cho H.
        • In T.S.
        • Cho K.H.
        • Song C.H.
        A single trial of transcutaneous electrical nerve stimulation (TENS) improves spasticity and balance in patients with chronic stroke.
        Tohoku J Exp Med. 2013; 229: 187-193
        • Potisk K.P.
        • Gregoric M.
        • Vodovnik L.
        Effect of transcutaneous electrical nerve stimulation (TENS) on spasticity in patients with hemiplegia.
        Scand J Rehabil Med. 1995; 27: 169-174
        • Levin M.F.
        • Hui-Chan C.W.
        Relief of hemiparetic spasticity by TENS is associated with improvement in reflex and voluntary motor functions.
        Electroencephalogr Clin Neurophysiol. 1992; 85: 131-142
        • Bernhardt J.
        • Hayward K.S.
        • Kwakkel G.
        • et al.
        Agreed definitions and a shared vision for new standards in stroke recovery research: the Stroke Recovery and Rehabilitation Roundtable taskforce.
        Int J Stroke. 2017; 12: 444-450
        • Cochrane Effective Practice and Organisation of Care
        Suggested risk of bias criteria for EPOC reviews.
        (Available at:) (Accessed August 22, 2018)
        • Higgins J.P.
        • Green S.
        Cochrane handbook for systematic reviews of interventions: version 5.1.0.
        (Available at:) (Accessed August 27, 2018)
        • Hussain T.
        • Mohammad H.
        The effect of transcutaneous electrical nerve stimulation (TENS) combined with Bobath on post stroke spasticity. A randomized controlled study.
        J Neurol Sci. 2013; 4: 22-29
        • Park J.
        • Seo D.
        • Choi W.
        • Lee S.
        The effects of exercise with tens on spasticity, balance, and gait in patients with chronic stroke: a randomized controlled trial.
        Med Sci Monit. 2014; 20: 1890-1896
        • Laddha D.
        • Ganesh G.S.
        • Pattnaik M.
        • Mohanty P.
        • Mishra C.
        Effect of transcutaneous electrical nerve stimulation on plantar flexor muscle spasticity and walking speed in stroke patients.
        Physiother Res Int. 2016; 21: 247-256
        • Hui-Chan C.W.
        • Levin M.F.
        Stretch reflex latencies in spastic hemiparetic subjects are prolonged after transcutaneous electrical nerve stimulation.
        Can J Neurol Sci. 1993; 20: 97-106
        • Karakoyun A.
        • Boyraz İ.
        • Gunduz R.
        • Karamercan A.
        • Ozgirgin N.
        Electrophysiological and clinical evaluation of the effects of transcutaneous electrical nerve stimulation on the spasticity in the hemiplegic stroke patients.
        J Phys Ther Sci. 2015; 27: 3407-3411
        • Koyama S.
        • Tanabe S.
        • Takeda K.
        • Sakurai H.
        • Kanada Y.
        Modulation of spinal inhibitory reflexes depends on the frequency of transcutaneous electrical nerve stimulation in spastic stroke survivors.
        Somatosens Mot Res. 2016; 33: 8-15
        • Okuma Y.
        • Lee R.G.
        Reciprocal inhibition in hemiplegia: correlation with clinical features and recovery.
        Can J Neurol Sci. 1996; 23: 15-23
        • Sommerfeld D.K.
        • Gripenstedt U.
        • Welmer A.-K.
        Spasticity after stroke.
        Am J Phys Med Rehabil. 2012; 91: 814-820
        • Fernández-Tenorio E.
        • Serrano-Muñoz D.
        • Avendaño-Coy J.
        • Gómez-Soriano J.
        Transcutaneous electrical nerve stimulation for spasticity: a systematic review.
        Neurologia. 2016; (pii: S0213-4853(16)30111-6)
        • Kwong P.W.
        • Ng G.Y.
        • Chung R.C.
        • Ng S.S.
        Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysis.
        Clin Rehabil. 2018; 32: 1203-1219