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ORIGINAL ARTICLE

Stimulation with High-frequency TENS Effects on Lower Limb Spasticity after Stroke
L. SONDE , RPT 1, H. KAL I M O, MD, PhD1,2 and M. V I I T ANE N, MD, PhD1 From the 1Division of Geriatric Medicine, Karolinska I nstitutet, Huddinge University Hospital, Huddinge, Sweden; 2Department of Pathology, Turku University Hospital, Turku, Finland

Abstract
The objective was to evaluate whether high-frequency (100 Hz) transcutaneous electrical nerve stimulation (HiTENS) on a speci c acupuncture point would alleviate spasticity in a paretic leg after stroke. A clinical study with a one-group pretest post-test design was used and 16 patients were included. The electrodes were placed in order to stimulate acupuncture point ST 36, and treatment was given for 30 min daily over a period of 3 months. A six-point

modi ed Ashworth scale was used to measure spasticity and in a 10-m gait test the time was measured. Motor function was assessed with the Fugl Meyer motor performance scale. A signi cant reduction of spasticity was seen after completion of treatment and 10 patients had reduced spasticity 2 weeks after the end of the treatment. The reduction of spasticity could be seen in knee extensor muscles as well as in plantar exor muscles. In patients gait time a signi cant improvement was

seen although no changes were seen in motor function. The results of this study suggest that stimulation of the acupuncture point ST 36 with high-frequency (100 Hz) TENS could be a clinical method to reduce spasticity in paretic leg after stroke. A larger controlled study is needed to corroborate the results.
KEY WORDS: Acupuncture afferent

stimulation TENS stroke rehabilitation.

INTRODUCTION Spasticity usually develops several weeks after stroke following a period of accid paresis. Increased motor neuron activity can lead to contractures, most often involving the elbow exors, knee extensors and plantar exors. Spasticity may even block motor functions and:or cause pain. In a study on 120 patients with spastic hemiplegia after stroke it was shown that increased a-motor neuron activity, often secondary to altered presynaptic activity at the spinal cord level, was the main segmental cause of the spasticity (1). Spasticity after spinal injury has been successfully treated with stimulation of speci c acupuncture points daily for 3 months with transcutaneous electric nerve stimulation (TENS). Han et al. (2,3) offered a neuropharmacological explanation for the inhibition and demonstrated that naloxone partly blocked the anti-spastic effect of electrical stimulation. On this basis they suggested that high-frequency (100 Hz) TENS (Hi-TENS) induced release of dynorphin reduces a-motor neuron activity and
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thereby spasticity. In their study Han et al. also pointed out that only Hi-TENS and not low-frequency (2 Hz) TENS (Low-TENS) at speci c acupuncture points had an effect on reducing spasticity. TENS reduces lower limb spasticity in hemiparetic patients (4 9). The effect is usually only short lasting, from minutes to a few hours. Al eri (4) noted not only an immediate but also a permanent reduction for 4 to 16 weeks after a number of treatment sessions. However, comparison of different studies is dif cult, because there is great variation in the type of treatment, the area stimulated, as well as intensity and duration of treatment given. Neither is there any study in which the optimal parameters for TENS have been determined. Notably, the majority of studies showing positive effects on spasticity have used some type of high frequency stimulation. Treatment with electrical stimulation needs to be standardized. The purpose of this pilot study was to examine whether long-term continuous treatment
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with Hi-TENS on a speci ed acupuncture point, ST 36, alleviated spasticity in the paretic leg after stroke.

METHODS Sixteen hemiplegic patients with a measurable spasticity ( \ 1 according to the modi ed Ashworth scale) in knee extensor muscles and:or plantar exor muscles were enrolled in the study. The group consisted of 12 men and four women. They were all living at home and had had a stroke at least 5 months earlier. Their average age was 68 years (range 51 78) and the time period since the stroke was on average 12 months (range 5 26). Nine of 16 patients had a left-sided and seven a right-sided paresis. Most patients had only minor impairment of Activities of Daily Living (ADL) index score (Barthel-index median 80). Ten patients received physiotherapy at a day-care center once or twice a week. All patients gave an informed consent to treatment procedures, as approved by the Ethical Committee of Huddinge University Hospital. Patients received Hi-TENS for 30 min every day during a 3-month period. A physical therapist introduced and gave the rst treatment at each patients home, after which the treatment was continued by the patients themselves. The level of compliance with the daily Hi-TENS treatment was recorded by the patient in a protocol. The TENS equipment used was a Cefar Dual unit (Cefar Medical Products AB, Lund Sweden), which at a high-frequency setting emits a stimulation frequency of 100 Hz. The intensity of the TENS could be selected between 0 and 60 mA. Patients were asked to choose the intensity level so that stimulation could be sensed, but was not painful. Self-adhering rubber electrodes, size 54 34 mm, were used. The negative electrode was placed over the acupuncture point ST 36, which is situated at the lower lateral side of the knee joint. The positive electrode was placed dorsally on the lower leg, approximately 10 cm distal to the knee joint (Fig. 1). The electrodes covered a large area including the common peroneal nerve (L4-S2). All measurements were done in the patients home. Spasticity, gait and motor function (order in the sequence) were assessed at the beginning and after 3 months of treatment. Follow-up measurement of spasticity was done 2 weeks after the last treatment.
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A mean score from three continuous daily measurements of spasticity was used as a baseline. These measurements were made independently by two physical therapists. Spasticity in the paretic leg was assessed with a modi ed Ashworth scale (six degrees) where 0 represents normal muscle tone and 5 that the affected part is rigid in exion or extension (10 12). This test was performed with the patient in supine position. In the gait test, the patient was asked to walk 10 m and the time was measured (13). The Fugl Meyer motor performance score (FM-score) was used to evaluate changes in motor function in the lower extremity. In this scale a score of 0 represents no motor activity and a score of 34 intact motor function in the leg. This test is often used in stroke research and its reliability and validity are well-documented (14,15). Statistical analysis Mean values and standard deviations of the measured parameters were calculated. Friedman analysis of variance (ANOVA) and Kendall Concordance were used to evaluate any pre- and post-TENS changes on the clinical scores (Ashworth, FM and gait time). Analyses were performed with the Statistica 4.1 for the Macintosh (StatSoft, Inc. 1991 94).

RESULTS Eleven out of 16 patients had measurable spasticity in the knee extensor muscles at baseline and 14 out of these 16 had measurable spasticity in plantar

Fig. 1. Electrode placement used to stimulate acupuncture point ST 36.

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TABLE I: Average scores (9 SD) in Ashworth, gait time and FuglMeyer (FM) pre- and post-TENS and results of Friedman analy sis of varianc e (ANOVA)
Variables (n) Ashworth score: Knee extensor muscles (11) Plantar exor muscles (14) Gait time, m:s (13) FM motor performance score (16) Pre-TENS (SD) Post-TENS (SD) p-value

2.1 (0.8) 2.1 (1.0) 0.30 (0.33) 21.3 (5.4)

1.3 (0.9) 1.6 (0.8) 0.40 (0.40) 21.9 (5.2)

0.01 0.02 0.02 0.74

exor muscles at baseline. Stimulation with HiTENS over the acupuncture point ST 36 decreased spasticity in knee extensor muscles and in plantar exor muscles signi cantly (Table I). Spasticity remained at a reduced level when controlled 2 weeks after treatment (Fig. 2). The gait time increased signi cantly following Hi-TENS (Table I). Eleven of 14 patients achieved a better gait time. One of three patients who could not perform the gait test at the beginning was able to perform the test at the end of the treatment. No signi cant changes were seen in motor function assessed with the FM scale.

DISCUSSION The results of our clinical study indicate that daily treatment in a 3-month scheme with Hi-TENS over acupuncture point ST 36 reduces spasticity both in plantar exors and knee extensor muscles, and that this effect persists for at least 2 weeks after the last treatment. These changes occurred with an improvement in gait ability. In our study the lack of placebo-treated controls does not allow any far-reaching conclusions. However, it is important that our results agree with earlier reported effects of TENS treatment, including studies where the Ashworth scale was used for assessments of spasticity (4,9). Our results suggest that stimulation of acupuncture point ST 36 in uences a greater number of spinal cord segments, because both thigh and lower leg muscles responded to the treatment. The rubber electrodes were placed over ST 36 but they were covering a larger area that can also affect the results. In the study from Tekeodly et al. (9) the electrodes were attached to the skin over the com-

mon peroneal nerve posterior to the head of the bula on the hemiparetic leg. This area is similar to the acupuncture point ST 36 used in our study. Our treatment scheme gave a persistent spasticity-reducing effect for 2 weeks, in agreement with the results of Al eri (4). This persistence could be due to a lowering of the threshold for dynorphin release or sensitization of receptors for dynorphin by continuous stimulation (3). An alternative hypothesis is that long-term stimulation changes the processing of signals at the spinal cord level a form of spinal plasticity. Okuma and Lee (16) noted that stroke patients who experienced good recovery, with no or only mild remaining spasticity,

Fig. 2. Mean changes in Ashworth score after 3 months of daily Hi-TENS treatment of acupuncture point ST 36 for knee extensor muscles and for plantar exor muscles. *Signi cant difference between spasticity assessed at baseline and after treatment period or at 2 weeks follow-up.

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had a compensatory increased 1a inhibition of soleus motor neurons, compared to healthy controls. They suggested that this could be due to a mechanism during recovery that compensated for the lack of central control. Electrical stimulation could intensify this compensatory mechanism. Acupuncture point ST 36 was stimulated with surface electrodes instead of acupuncture needles. In a review, Balogun et al. (17) concluded that electrical stimulation of acupuncture points with surface electrodes is a relatively new and non-invasive treatment with potential clinical application, and can elicit the same physiological and therapeutic effects as those produced by acupuncture and electroneedling techniques. In the present study, 10 patients received physiotherapy at a day-care center once or twice a week, which could in uence the results. It is unknown whether any of the patients received treatment aimed speci cally at reducing spasticity. Level of compliance with the daily TENS treatment was recorded by the patient in a protocol. The absence of effect in some of the patients may of course be due to their not carrying out the TENS treatment as prescribed.

REFERENCES 1. Milanov I. Examination of the segmental pathophysiological mechanisms of spasticity. Electromyogr Clin Neurophysiol 1994;34:73 9.
2. Han JS, Chen XH, Yuan Y, Yan SC. Transcutaneous electrical nerve stimulation for treatment of spinal spasticity. Chin Med J 1994;107:6 11. 3. Han JS, Chen XH, Sun SL, et al. Effect of lowand high-frequency TENS on Met-enkephalin-ArgPhe and dynorphin A immunoreactivity in human lumbar CSF. Pain 1991;47:295 8. 4. Al eri V. Electrical treatment of spasticity. Scand J Rehab Med 1984;14:177 82. 5. Hui-Chan CW, Levin MF. Stretch re ex latencies in spastic hemiparetic subjects are prolonged after transcutaneous electrical nerve stimulation. Can J Neurol Sci 1993;20:97 106. 6. Levin MF, Hui-Chan CWY. Relief of hemiparetic spasticity by TENS is associated with improvement in re ex and voluntary motor functions. Electroencephalogr Clin Neurophysiol 1992;85:131 42. 7. Potisk KP, Gregoric M, Vodovnik L. Effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in patients with hemiplegia. Scand J Rehab Med 1995;27:169 74. 8. Seib TP, Price R, Reyes MR, Lehmann JF. The quantitative measurement of spasticity: effect of cutaneous electrical stimulation. Arch Phys Med Rehabil 1994;75:746 50. 9. Tekeodly Y, Adak B, Goksoy T. Effect of tran scutaneous electrical nerve stimulation (TENS) on Barthel Activities of Daily Living (ADL) Index score following stroke. Clin Rehab 1998;12:277 80. 10. Ashworth B. Preliminary treatment of carisoprodol in multiple sclerosis. Practitioner 1964;192:540 2. 11. Bohannon RW, Smith MD. Interrater reliability of a modi ed Ashworth scale of muscle spasticity. Phys Ther 1987;67:206 7.

CONCLUSIONS Taken together, results of the present study and previously published results suggest that stimulation of acupuncture point ST 36 with high-frequency (100 Hz) TENS could be a clinical method for electrical stimulation on spasticity in the paretic leg after stroke. A larger controlled study is needed to corroborate our results and further studies would be needed to specify optimal duration of treatment and compare electrode places as well as determine those patients who would bene t from this treatment. ACKNOWLEDGEMENTS The authors are greatly indebted to Jan-Eric Wedlund, MD, Agneta Soderlund, medical secretary, Marie Lund, RPT and Dan Gustavsson RPT for their assistance in recruiting patients. This work was supported by funds from The Regional Social Insurance Of ce in collaboration with The Stockholm County (Dagmar-Funds), Foundation for Stroke Research and Foundation of Gamla Tjanarinnor. TENS-equip ment was provided by Cefar Medical Products AB.
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12. Wade DT. Measurement in neurological rehabilitation. Oxford: Oxford University Press, 1992: 162 4. 13. Collen FM, Wade DT, Bradshaw CM. Mobility after stroke: reliability of measures of impairement and disability. Int Disabil Stud 1990;12:6 9. 14. Duncan PW, Propst M, Nelson SG. Reliability of the Fugl Meyer assessement of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983;63:1606 10. 15. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient: a method for evaluation of physical performance. Scand J Rehab Med 1975;7:13 31. 16. Okuma Y, Lee RG. Reciprocal inhibition in hemiplegia: correlation with clinical features and

recovery. Can J Neurol Sci 1996;23:15 23. 17. Balogun JA, Biasci S, Han L. The effects of acupuncture, electroneedling and transcutaneous electrical stimulation therapies on peripheral haemodynamic functioning. Disabil Rehabil 1998;20:41 8.
ADDRESS FOR CORRESPONDENCE:

Lars Sonde RPT Division of Geriatric Medicine, B 56 Huddinge University Hospital SE-141 86 Stockholm, Sweden E-mail: lars.sonde@ger.hs.sll.se Submitted 17 January 2000; accepted for publication 12 May 2000

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