Disability & Rehabilitation, 2012; 34(2): 151–156

Copyright © 2012 Informa UK, Ltd.

ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.593679

Research paper

The efficacy of electrical stimulation in reducing the post-stroke

spasticity: a randomized controlled study

Nilay Sahin, Hatice Ugurlu & Ilknur Albayrak

Physical Medicine and Rehabilitation Department, Selcuk University, Meram Faculty of Medicine, Meram, Konya, Turkey
Disabil Rehabil Downloaded from informahealthcare.com by McMaster University on 06/13/13

Purpose: The purpose of this study is to evaluate the efficacy
of surface electrical stimulation on the spasticity occurring in
the wrist flexor muscles after a cerebrovascular event. Method:
Hemiplegic patients with stage 2–3 spasticity in the wrist
muscles based on the Ashworth scale were divided into two
groups. Both groups were applied stretching. One group was
additionally administered neuromuscular electrical stimulation
(NMES) to the wrist extensors, in the form of pulsed current,
For personal use only.
Implications for Rehabilitation:
• There is a wide range of treatment options for spas-
ticity, from conservative treatments (medications,
splint, physical treatment modalities, and exercise)
to surgery.
• The efficacy of electrical stimulation in spasticity is
still controversial.
• Electrical stimulation treatment applied together with

100 Hz, with a pulse duration of 0.1 msec, and a resting

duration of 9 seconds, for 15 minutes to provide the maximum
muscular contraction. The efficacy of the treatment was
evaluated using the following: modified Ashworth scale (MAS),
Fmax/Mmax ratio, Hmax/Mmax ratio, wrist extension range of
motion (ROM). The daily activities were assessed by Functional
Independence Measurement (FIM) and the motor recovery was
evaluated by Brunnstrom motor staging. Results: Both groups
revealed a significant recovery after the treatment based on
the MAS, the electrophysiological evaluation results, wrist
ROM, FIM and Brunnstrom motor staging. The group receiving
the combined treatment showed a better recovery in terms of
MAS, wrist ROM, FIM and Brunnstrom motor staging compared
to the group doing the stretching alone. Conclusions: The
results of this study showed that NMES given together with
stretching of the wrist extensor muscles was more effective
than stretching of the wrist extensor muscles alone in reducing
spasticity.
Keywords:  electrical stimulation, spasticity, stretching, stroke
Introduction
Spasticity is a component of the upper motor neuron dis-
eases characterized by an increased speed-associated tonic
stretching reflex and an increased tendon reflex due to the
hyperexcitability of the stretching reflex. Spasticity may cause
muscle weakness, muscle shortness and development of joint
deformities leading to a limitation in the daily activities of the
wrist extensor muscles passive stretching exercise is
effective in reducing spasticity.
patients. Besides, these findings are the main reasons of the
disability observed in spastic patients [1–3].
Among the upper motor neuron diseases, spasticity in the
upper extremity that develops in hemiplegia is more common
in the flexor muscles of the wrist [1].
While depending on the region of spasticity, main objectives
of the treatment include increasing range of motion (ROM),
decreasing pain and enabling mobility. There is a wide range
of treatment options for spasticity, from conservative treat-
ments (medications, splint, physical treatment modalities, and
exercise) to surgery [4]. Among them, exercise is extremely
important. Passive stretching increases intramuscular tension,
which stimulates golgi tendon organs, a protective mechanism
that inhibits muscle contraction, enabling muscle relaxation.
Stretching exercise is the basic treatment approach for spastic-
ity. There are different types of stretching exercises by the appli-
cation techniques. The most commonly recommended type for
neuromuscular problems is the proprioceptive neuromuscular
facilitation (PNF). This technique is a stretching technique that
provides the highest flexibility by stretching the muscles. Some
researchers suggest that cold or hot treatment before stretching
increases the success of stretching [5,6]. As a physical treat-
ment modality, neuromuscular electrical stimulation (NMES)
reduces spasticity by providing relaxation in the agonist muscles

Correspondence: Dr. Nilay Sahin, Physical Medicine and Rehabilitation Department, Selcuk University, Meram Faculty of Medicine, Meram, Konya,
Turkey. E-mail: nilaysahin@gmail.com

151
 152  N. Sahin et al.
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For personal use only.
Figure 1.  Flow diagram showing how the study group was formed and the number and group membership of dropouts throughout the course of
the study.
or strength in the antagonist muscles [7,8]. However, although
there are numerous studies on the efficacy of electrical stimula-
tion (ES) in spasticity, the efficacy is still controversial [9,10].
ES decreases the spasticity by increasing Ib fiber activation, via
mechanisms facilitating the Renshaw cell recurrent inhibition,
antagonist reciprocal inhibition and increased cutaneous sen-
sory stimuli [9,10]. We could not find any study in the literature
evaluating the effects of concomitant administration of these
two treatment options in the spasticity in the forearm flexors
in adults. The purpose of this study is to evaluate the efficacy
of NMES applied with stretching in the flexor spasticity that
developed in the upper extremities following stroke.
Material and methods
The study included 50 patients between 45–65 years of age,
who had developed forearm flexor spasticity following a
stroke. Inclusion criteria were hemiplegia for longer than 1
year, score 2 or 3 spasticity according to Modified Ashworth
Scale (MAS) and a stable neurological state. Exclusion cri-
teria included the presence of unstable comorbid diseases,
sensory deficit, anti-spastic medication usage, treatment with
the botulin toxin in the last six months, history of epileptic
seizures, cardiac pacemaker, severe depression (patients with
a score of 18 points on the Beck Depression Index), pres-
ence of frequent urinary infections and shoulder pain (over
5 based on visual analogue scale). Forty-four patients who
met the inclusion and exclusion criteria were enrolled into the
study. All patients were informed about the study procedures
and their written/oral informed consents were obtained. The
study was approved by the Ethics Committee.
Randomization
Forty-four patients were randomized to Group 1 to receive
stretching with PNF after hot treatment with infrared and
NMES (Combines Treatment Group = CTG) and to Group
2 to receive PNF alone after hot treatment with infrared
(PNF Group = PG) after being coded by the electronically
randomized numbers using the sealed opaque envelopes. An
investigator (N.S.), who was not involved in the selection and
allocation of patients, prepared these envelopes. The assign-
ment of the patients was conducted by two investigators after
the patients had completed a baseline questionnaire to collect
demographic and prognostic information. One patient who
had a trauma due to falling and another patient with personal
reasons discontinued from the study (Figure 1).
Intervention
1. Stretching with PNF technique was applied to the upper
extremity after 15 minutes of infrared hot treatment on
the extensor muscle. Movement components of this tech-
nique include shoulder, scapula, forearm, wrist and finger
flexion-extension, abduction-adduction, and internal-
external rotation.
Disability & Rehabilitation

2. NMES was applied to the wrist extensors, in the form of
pulsed current, 100 Hz, with a pulse duration of 0.1 msec
and pulse intervals of 0.9 msec, in cycles of 3 msec, and a
resting duration of 9 seconds, for 15 minutes to provide
maximum muscular contraction. Cathode was placed on
the most excitable region of the muscle and anode was
placed on a region close to the lateral epicondyle.
 All patients received stretching with PNF applied to the
upper extremity after hot treatment with infrared, 5 days a week
for 20 sessions. Group 1 additionally received NMES treatment
to the wrist extensors for 5 days a week, 20 sessions in total.
Evaluation criteria
1. The degree of spasticity was evaluated by the MAS. 0
point represented no spasticity while 5 points indicated
maximum spasticity [11].
2. Passive ROM of wrist: wrist extension was assessed by
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Efficacy of electrical stimulation on spasticity  153
treatment, Wilcoxon Signed Ranks test was applied within
the group and Mann–Whitney U-test was applied between
the groups. Statistical significance level was p < 0.05.
Results
Table I shows the demographical data for both groups. There
was no significant difference between the groups in terms of
age, gender, duration of hemiplegia, MAS, (p > 0.05).
Baseline values for MAS, wrist ROM, Brunnstrom motor
staging, Fmax/Mmax and Hmax/Mmax showed no sig-
nificance between the groups, but FIM exhibited significance
between the two groups for pretreatment values (p = 0.01).
MAS showed a significant decrease in the spasticity
after the treatment in both groups (p = 0.003 and p = 0.008,
respectively) (Table II). CTG group showed a statistically
significantly better improvement than the PG group after the

goniometer. treatment (p = 0.001) (Table III).

3. Electrophysiological evaluation: Fmax/Mmax ratio:
Records were obtained using electrodes over abductor
pollicis brevis muscle for the F wave and the M response.
M-F waves were obtained by applying a total number of
15 consecutive stimuli of 0.5 Hz by supramaximal stimu-
lation. A normal Fmax/Mmax ratio had to be below 5%
[12]. Hmax/Mmax amplitude ratio: H reflex is obtained
by the electrodes placed in the middle of the flexor carpi
For personal use only.
Both groups showed a significant improvement in the wrist
extension ROM after the treatment (p = 0.001) (Table II). A
more pronounced increase was observed in the CTG group
compared to the PG group after the treatment (p = 0.001)
(Table III).
Both groups exhibited a significant improvement in the
Brunnstrom motor staging after the treatment (p = 0.02 and
p = 0.03, respectively) (Table II). The CTG group displayed
a significantly better improvement than the PG group after

radialis muscle and its tendon, and stimulation of median

nerve at the level of elbow. Stimuli are applied at a rate of the treatment (p = 0.04) (Table III). The total FIM value was
once every 5 seconds at 0.2 Hz. The duration of the stimu- significantly increased in both groups after the treatment
lus duration was 0.5 msec. Once appropriate H reflex was (p = 0.01 and p = 0.03, respectively) (Table II). CTG group
obtained, the frequency of the stimulus was changed. The showed a significantly higher increase than the PG group after
mean value was between 0.04 and 0.75 [13]. the treatment (p = 0.028) (Table III).
4. Motor evaluation: Brunnstrom method is a neurophysi- Electrophysiological evaluation showed a significant
ological approach that evaluates the patients in 6 stages decrease in the Fmax/Mmax ratio after the treatment in both
based on the spasticity and synergy development. Thus, the groups (p = 0.001 and p = 0.001, respectively) (Table II). There
neurological recovery of the patient after stroke was evalu- was no significant difference between the two groups after the
ated and the treatment regimen was designed according to treatment (p = 0.343) (Table III). Hmax/Mmax ratios were
the stage of recovery established by this method. The evalu- obtained at the upper limit of the normal values. Hmax/Mmax
ation was performed separately for the arm, the hand-wrist ratio showed a significant reduction after the treatment in
and the lower extremity. A higher stage of Brunnstrom
represented a better status of the individual [14]. Table I.  Characteristic properties of the patients.
5. Functional Independent Measurement (FIM) is a scale Groups
evaluating 13 motor, 5 social-cognitive states on a scale of
CTG PG
18–126 (dependent in all areas-independent in all areas). (n: 21) (n: 21) p
It is composed of 7 progressive sub-scales evaluating self- Age (years) 60.2 (6.2) 59.3 (9.3) 0.91*
care, sphincter control, transfer, movement, communica- Sex (F:M) 10:11 09:12 0.84**
tion, social relationships and cognitive state [15,16]. Duration (months) 25.0 (14.6) 35.1 (24.4) 0.19***
 All patients received 1 month of treatment in total. All Wrist spasticity (MAS) 3 2.8 0.85**
patients were evaluated based on MAS, Fmax/Mmax ratio, Wrist extension ROM 8.5 (4.1) 7.9 (4.6) 0.67***
Hmax/Mmax ratio, ROM of wrist, Brunnstrom motor staging (degrees)
and functionally by FIM before and after a short period of the Brunnstrom motor 3.1 3 0.85**
scale (upper)
treatment. FIM total 107.7 (18.9) 101.7 (19.6) 0.01**
Fmax/Mmax (%) 8.2 (3.6) 8.0 (3.5) 0.98***
Statistical analysis Hmax/Mmax amp 0.68 (0.16) 0.68 (0.11) 0.99***
Categorical and continuous data were assessed using the CTG, Combine treatment group; PG, PNF group.
*Chi-square.
χ2-square, Mann–Whitney U-test and independent sample **Mann–Whitney U-test.
t-test. In the evaluation of the attempts before and after the ***Independent sample t-test.

Copyright © 2012 Informa UK Ltd.

 154  N. Sahin et al.

Table II.  Comprasion of parameters before and after the treatment programme in both groups.
CTG PG
BT AT BT AT
Parameters  Mean (SD) Median Mean (SD) median P Mean (SD) median Mean (SD) median P
Wrist spasticity (MAS) 3.2* 1.8* 0.003 3.0* 2* 0.008
Wrist extension ROM (degrees) 8.5 (4.1) 25.0 (6.2) 0.001 7.9 (4.6) 23.8 (5.6) 0.001
Brunnstrom motor scale (upper) 3.2* 4.5 0.02 3.1* 4* 0.03
FIM total 107.7 (18.9) 109.8 (18.8) 0.01 101.7 (19.6) 102.7 (19.6) 0.03
Fmax/Mmax (%) 8.2 (3.6) 3.6 (3.0) 0.001 8.0 (3.5) 3.5 (2.9) 0.001
Hmax/Mmax amp 0.68 (0.16) 0.27 (0.15) 0.001 0.68 (0.11) 0.25 (0.19) 0.001
*Median
BT, before treatment; AT, after treatment.

Table III.  Mean changes of parameters after intervention in both groups. found NMES to be effective in reducing spasticity, although
CTG PG not functional [19]. Some of the previous studies evaluated the
Parameters Mean change Mean change P efficacy of ES and medical treatment in the treatment of spastic-
Wrist spasticity (MAS) −1.4 −1 0.001 ity seen in patients with multiple sclerosis, and the combined
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Wrist extension ROM 16.5 15.9 0.001 usage of both approaches was shown to increase the treatment
(degrees) success [20]. Studies performed on the upper extremity spastic-
Brunnstrom motor scale 1.2 0.9 0.04 ity treatment demonstrated that combination of ES and splint
(upper)
FIM total 2.1 1 0.028
usage in patients with cerebral palsy was highly effective [21].
Fmax/Mmax (%) −4.6 −4.5 0.343
In summary, the studies performed in patients who developed
Hmax/Mmax amp −0.41 −0.43 0.387
spasticity due to upper motor neuron system conditions such as
cerebral palsy or hemiplegia showed that NMES was an effec-
tive treatment option. In the present study, we have observed a
both groups (p = 0.001 and p = 0.001, respectively) (Table II). decrease in spasticity in both groups with significant improve-
There was no significant difference between two groups ments in the MAS, wrist ROM, electrophysiological evaluation,
For personal use only.

after the treatment (p = 0.387) (Table III).
Discussion
In this randomized controlled study, we have observed that PNF
stretching exercise and NMES added to this exercise provided
significant improvements in the MAS, electrophysiological
evaluation, wrist ROM, FIM and the Brunnstrom motor stat-
ing in patients with hemiplegia. The results of the present study
have demonstrated that NMES applied along with PNF stretch-
ing exercise was more effective than PNF stretching exercise
alone in the treatment of spasticity in hemiplegic patients.
PNF stretching technique affects spasticity by autogenic and
reciprocal inhibition pathways, facilitating its reduction. This
technique includes a combination of relaxation in both ago-
nist/antagonist muscles and alternative isometric and isotonic
muscle contractions [5,6]. This affects results in a decreased
spasticity and a better motor ability. NMES on the other hand
can be applied to both agonist/antagonist muscles. The purpose
for applying NMES to the antagonist muscle is to strengthen this
muscle and help it to positively affect the spasticity [7–9]. Since
the studies performed to investigate the effects of NMES on
spasticity employed different protocols (stimulation, evaluation
parameters and methods), the study results show a great vari-
ability. Besides, most of these studies included lower extremity
spasticities. In a study performed by Santos et al., NMES applied
to both flexor and extensors of the wrist was shown to decrease
the spasticity in hemiplegic patients and beneficially affect
the hand-finger functions [17]. Baker et al. have reported that
NMES applied to the spastic wrist muscles had healing effects
on spasticity and ROM [18]. Hummelsheim et  al., in their
study evaluating the spasticity in the hand and finger muscles,
motor and functional status. PNF stretching applied along with
NMES was found to be more effective.
Electrophysiological evaluations did not reveal any sig-
nificant difference between the two groups in our study.
Electrophysiological evaluations are important to assess the
degree of spasticity that develops as a result of the upper
motor neuron lesions. However, the results of the studies
performed to evaluate the efficacy of spasticity treatment are
controversial. For example, while some studies have shown a
correlation between the MAS and Hmax/Mmax, some oth-
ers suggested no relationship between these two parameters
[22–24]. Nevertheless, studies investigating spasticity treat-
ment demonstrated the success of NMES treatment by elec-
trophysiological assessments [9,10]. These studies involved
evaluation of H reflex amplitude, Hmax/Mmax ratio, Fmax/
Mmax ratio and F wave persistence. However, most of
these studies are for the treatment of the lower extremity
spasticities. Chen et  al. observed a decrease in the Fmax/
Mmax ratio following ES [9]. Bakhtiary et al. also observed
a decrease in the Hmax/Mmax amplitude ratio after NMES
application; however, this decrease was observed in the two
groups, of which one was administered the Bobath inhibitor
technique, and the other was administered NMES combined
with Bobath inhibitor technique for the treatment of spastic-
ity. Electrophysiological evaluation results were not different
between the two groups [10]. In another study, spasticity was
demonstrated to be decreased without any electrophysiologi-
cal changes [25]. Studies have shown that stretching tech-
niques also had different effects on the electrophysiological
parameters. Different studies have observed that electrophysi-
ologic parameters were reduced, not affected or increased by

Disability & Rehabilitation


application of the stretching techniques [26–28]. In our study,
electrophysiological evaluation showed a significant decrease
in the Fmax/Mmax and Hmax/Mmax ratios in both groups,
while the results did not show any significant Fmax/Mmax or
Hmax/Mmax changes between the two groups. Consequently,
NMES added to the treatment appears not to affect, whereas
the PNF stretching technique affects the electrophysiological
values in our study. One of the reasons may be the reduced
amplitude of the M-wave due to the muscle fatigue after
applying NMES. Consequently, NMES application does not
affect the Fmax/Mmax or H/maxMmax [10]. As for the other
reason, no further reduction may be seen in these ratios due to
the normal range of electrophysiological values obtained after
the treatment. As another reason, because nerve conduction
studies are also affected by many factors (e.g., temperature,
positioning, location of electrod) on repeated measurement,
the small changes may not be obtained in the measurements
Disabil Rehabil Downloaded from informahealthcare.com by McMaster University on 06/13/13
[10]. The reason why the stretching techniques have different
effects on the electrophysiological values in the studies may
be the different stretching techniques used. The decreased H
reflex may be caused by autogenic inhibition pathway of the
PNF stretching technique that was applied in our study. In
summary, the previous studies support that electrophysiologi-
cal results can show variability in the treatment of spasticity
and may not correlate with physical examination. This situa-
tion may be associated with different stretching and stimula-
tion applications used.
For personal use only.
Limitations of the study: because the results of this study
were evaluated immediately after the treatment, these results
showed the short-term effect of the treatment. NMES was
applied to the wrist extensor muscles; the purpose of this
treatment was to strengthen this muscle. If the muscle strength
and the muscle fatigue had been measured by isokinetic dyna-
mometer, that would give an objective value of the muscle
strength and fatigue, and thus perhaps we could have a better
understanding of the mechanism of action of the NMES and
the reason for the absence of a significant difference between
the two groups in the electrophysiological measurements. The
PG should have received a placebo NMES treatment. Thus, a
trial comparing the placebo NMES and the real NMES appli-
cations would evaluate the expected improvement obtained
and determine the precise efficacy of the real NMES applica-
tion. The high expectancy for improvement in patients lead
to high rates of response in the placebo controlled patients.
The trials performed demonstrated a more marked clinical
improvement in patients with a high expectancy compared to
those with a low expectancy for improvement. In addition,
some studies have shown that placebo could affect the neu-
robiological changes. Such an effect could have contributed
to the determination of the real efficacy in the two groups
[29,30]. Based on the results of our trial, both groups exhib-
ited an improvement, which was detected to be statistically
more significant in the CTG group. Whether the statistical
difference is also clinically significant between the groups is
an important issue. The concept of minimal clinically impor-
tant difference (MCID), which helps to assess this associa-
tion, was started to be used to investigate the efficacy of the
rehabilitation therapies very recently and thus not included in
Copyright © 2012 Informa UK Ltd.
Efficacy of electrical stimulation on spasticity  155
the design of our trial [31]. However, even if we did not use
the MCID concept in our trial, the clinical review of our final
state measures revealed that the two groups would not exhibit
a high clinical difference. For example, the post-treatment
MAS value was detected to be 1.8 in the CTG group and 2 in
the PG group; on physical examination, the value of 1.8 would
be evaluated by the physician at a value of 2 for the degree
of spasticity. Therefore, a combined assessment of the clinical
and statistical significance is of importance in detecting the
efficacy of the treatment administered. In conclusion, clini-
cally, the two groups may not show a marked difference in our
trial. Therefore, new studies showing the relationship between
the MCID and the clinical significance in the treatment of
patients with spasticity are needed to be performed.
In conclusion, NMES treatment applied to strengthen the
antagonist muscles, used together with PNF stretching tech-
nique for the treatment of the upper motor neuron lesion-asso-
ciated spasticity is an effective treatment approach, can modify
significantly clinical measures of spasticity. However, more
studies are required to assess clinically efficacy of ES in the
treatment of the spasticity occurring in the upper extremity.
Declaration of interest: The authors report no conflicts of
interest.
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Disability & Rehabilitation