RESEARCH ARTICLES

The Effect of Transcutaneous Electrical

Nerve Stimulation on Spasticity in
Multiple Sclerosis Patients: A Pilot Study
Kadriye Armutlu, Ayd¸n Meriç, Nuray K¸rd¸,
Edibe Yakut, and Rana Karabudak

The aim of this study was to examine the effects of trans-
cutaneous electrical nerve stimulation on spasticity in
patients with multiple sclerosis. The study was carried out
in the Hacettepe University School of Physical Therapy
and Rehabilitation. The subjects in the study were 10
clinically definite, primary and secondary progressive
type multiple sclerosis outpatients with mild to moderate
spasticity in the plantar flexor muscles of the ankle.
Stimuli of frequency 100 Hz and pulse width 0.3 msec
were used 20 minutes per day for 4 weeks. Patients were
assessed by electromyography, Modified Ashworth Scale,
and Ambulation Index. Electromyography was per-
formed before and after the daily treatment of spastic
muscles with transcutaneous electrical nerve stimulation
in order to assess the effect on muscle relaxation. The
Modified Ashworth Scale and Ambulation Index were
used before and after 4 weeks’ treatment. After 4 weeks of
treatment, there were statistically significant reductions
in spasticity of both extremities as assessed by myoelectric
activity and the Modified Ashworth Scale (P < 0.05).
Ambulation Index level was not improved significant-
ly (P > 0.05).
Key Words: Multiple sclerosis—Spasticity—Transcutaneous
electrical nerve stimulation.
Medical management of spasticity emphasizes
pharmacologic and physical therapeutic approach-
es. Oral antispasticity drugs often cause generalized
weakness, particularly when used at higher doses,
and side effects of fatigue and dizziness are fre-
quently reported.3 Because of these side effects,
the addition of local muscle inhibition, such as with
botulinum toxin and physical therapy, would seem
to have advantages over oral medication alone.
Although botulinum toxin injection is effective, it is
costly. There are numerous physical therapy
approaches to inhibiting spasticity, including the
use of electrical stimulation. In particular, transcu-
taneous electrical nerve stimulation (TENS) has
been reported to decrease spasticity in hemiplegics
and spinal cord–injured patients.4-6 To our knowl-
edge, there have been no studies assessing the
effectiveness of TENS for spasticity in MS patients.
The aim of this pilot study was to examine the
effects of TENS in treating spastic MS patients.

S pasticity, a velocity-dependent response to

passive muscle stretch, is present in most
patients with multiple sclerosis (MS).1
Moderate to severe spasticity significantly limits
basic functions such as ambulation and activities of
PATIENTS AND METHODS

daily living.2
From Hacettepe University, School of Physical Therapy and
Rehabilitation, Ankara, Turkey (KA, AM, NK, EY); and
Departmant of Neurology, Hacettepe University Hospitals (RK).
Address correspondence and reprint requests to Kadriye
Armutlu PT. PhD. Assist Prof., Hacettepe University, School of
Physical Therapy and Rehabilitation, 06100, Samanpazar¸,
Ankara, Turkey. E-mail: karmutlu@hacettepe.edu.tr.
Armutlu K, Meriç A, K¸rd¸ N, Yakut E, Karabudak R. The Effect
of Transcutaneous Electrical Nerve Stimulation on Spasticity in
Multiple Sclerosis Patients. Neurorehabil Neural Repair
2003;17:79–82.
DOI: 10.1177/1094428103251603
Patients
This study was carried out in the Hacettepe
University School of Physical Therapy and
Rehabilitation. The subjects were 10 clinically defi-
nite7 MS outpatients with plantar flexor muscle
spasticity of mild to moderate degree according to
the Modified Ashworth Scale and who had primary
and/or secondary progressive MS. Patients with
relapsing-remitting–type MS were not included in
the study because spontaneous recovery could
obscure results in this relatively small sample. Only
ambulatory patients (classified as 6 or less on the
Kurtzke Expanded Disability Status Scale) (EDSS)8
who had been clinically stable for 3 months before
the study were included. Subjects were randomly

Copyright © 2003 The American Society of Neurorehabilitation 79

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Armutlu et al.
Table 1. Demographic Values
Characteristics Mean ± SD
Age (year) 34.7 ± 8.70
Gender 4 F (40%), 6 M (60%)
Onset of illness (year) 28.1 ± 2.38
Illness duration (year) 6.15 ± 1.95
MS type 2 PP (20%), 8 SP (80%)
EDSS score 4.86 ± 1.68
F = Female; M = Male, PP = Primary progressive; SP = Secondary
progressive; EDSS = Expanded Disability Status Scale.
selected from those patients who came for therapy
to our center and met the inclusion criteria. All of
the patients had been using low-dose oral anti-
spasticity drugs for different periods. However, the
patients in this study were given doses of medica-
tion that are suboptimal for control of spasticity, to
avoid drowsiness and relaxation of normal mus-
cles. No dose changes were made during the study.
Measurements
The severity of spasticity was assessed by myo-
electrical activity using an Enraf Nonius Myomed
electromyographic feedback apparatus before and
after the daily TENS treatment of spastic muscles.
Surface electrodes consisting of 2 active and 1 inac-
tive (ground) leads were used to record the electri-
cal activity of the gastro-soleus muscle. Active elec-
trodes were placed along the long axis of the mus-
cle over the medial and lateral heads of the gastro-
soleus. Surface electrodes consisted of round disks
with silver-silver chloride recording surfaces, which
were recessed within a plastic cup. Before applica-
tion of the surface electrodes, the skin was
scrubbed and cleaned to remove oils and dead skin
from the epidermis, thereby reducing potentially
high impedance sources during recording sessions.
If these elements are not removed, attenuated EMG
signals and increased noise levels may result. The
skin was completely dried before electrodes were
applied. Myoelectrical activity (expressed in micro-
volts) was recorded 3 times before and after each
TENS application. All recordings were made with
the patient relaxed in the supine position. Repeated
measurements and treatments were performed at
the same time of day to avoid the effect of diurnal
fluctuations in spasticity. The Modified Ashworth
Scale and Ambulation Index were evaluated9,10
before and after 4 weeks of treatment. The
sequence of experimental procedures was as fol-
lows: First EMG measurements were done, fol-
80
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lowed by Modified Ashworth Scale and Ambulation
Range
Index evaluations. TENS was then applied, after
which EMG recordings were performed, and final-
30-38 ly Modified Ashworth Scale and Ambulation Index
evaluations were repeated. All of the measure-
24-32
4-8 ments were completed during the same session.
2.5-6
Treatment
In the treatment protocol, TENS was applied to the
same spinal cord level as the selected spastic mus-
cle group, and carbonized silicone rubber elec-
trodes with electrolytic gel were used. For patients
with bilateral plantar flexor spasticity, the patient
was placed in a supine and extention position. One
electrode was placed at the middle of m. gastro-
soleus, and the other was placed laterally to plan-
tar surface of the foot. Both gastro-soleus muscles
were treated at the same time. A stimulation fre-
quency of 100 Hz and pulse width of 0.3 msec
(high frequency) were applied through a portable
multichannel SMS 104 Clinical TENS device, 20
minutes per day for 4 weeks. TENS was applied to
optimal level. No other treatment was administered
to the patients during the TENS treatment.
Statistical analysis
The effects of TENS treatment was evaluated using
the Wilcoxon Ranks test.
RESULTS
Ten patients (4 female and 6 male, 2 primary and 8
secondary progressive-type MS) were studied. The
mean age of these patients was 34.7 ± 8.70 years,
and mean MS duration was 6.15 ± 1.95 years. The
mean onset of illness was 28.1 ± 2.38 years, and
mean EDSS score at time of entry into the study
was 4.86 ± 1.68 (Table 1).
The TENS treatment resulted in reduction of
spasticity in both extremities, as measured by myo-
electrical activity and Modified Ashworth Scale (P <
0.05) (Table 2, Figures 1 and 2). Ambulation Index
did not improve (P > 0.05) (Table 2). Although the
effect of TENS was temporary, the differences
between the EMG amplitudes during the week
before treatment and the 4th week of treatment
were statistically significant (P < 0.05).
Neurorehabilitation and Neural Repair 17(2); 2003
 Effect of TENS on Spasticity in MS Patients

Table 2. Before and After Treatment Values (n = 10) µV RIGHT EXTREMITIES

10
Mean ± SD Mean ± SD 9
Measurements Before Treatment After Treatment 8
7
Modified Ashworth Scale 6
5
Right 2.30 ± 0.67 1.90 ± 0.56* 4
Left 2.21 ± 0.18 1.84 ± 0.08* 3
Ambulation Index 3.80 ± 0.15 3.72 ± 0.06 2
EMG Feedback (µV) 1
Right 5.73 ± 1.31 2.98 ± 0.95* 0
Left 5.30 ± 0.92 3.72 ± 0.72* 1st WEEK 2nd WEEK 3rd WEEK 4th WEEK
*P < 0.05. PRE-TREATMENT POST-TREATMENT

Figure 2. EMG biofeedback values of right gastro-soleus

µV 10 LEFT EXTREMITIES muscle, weekly.
9
8
7 quencies. Only high-frequency stimulation was
6
5
effective.13 Hui-Chan and Levin found that segmen-
4 tally and heterosegmentally applied TENS for 45
3 min caused an immediate increase in soleus H-
2
1 reflex latencies that was evident for up to 60 min
0 poststimulation over 75% of the time in 10 hemi-
1st WEEK 2nd WEEK 3rd WEEK 4th WEEK paretic patients.11 Joodaki et al. investigated the
effects of TENS on alpha motoneuron excitability.
PRE-TREATMENT POST-TREATMENT
The electrophysiological parameters of H reflex
Figure 1. EMG biofeedback values of left gastro-soleus and F wave were assessed for this purpose. After 3
muscle, weekly. min application of TENS (with pulses of 0.25 msec
at a frequency of 99 Hz) in 3 spastic hemiplegic
patients, the mean peak-to-peak amplitude of H
DISCUSSION reflexes and F waves, H/M and F/M ratios, was sig-
nificantly reduced and the mean latencies of H
Spasticity is a symptom that increases the severity reflexes and F waves was significantly increased.
of the disability in many neurological disorders. In Thus, this study also supported the conclusion that
treating spasticity, electrical stimulation can be TENS can reduce spasticity.14 Differences in the
used in a variety of forms and methods, including reported results of the above studies can probably
TENS. be ascribed to different assessment and treatment
Low-intensity repetitive electrical stimulation methodologies.
such as dorsal column stimulation and TENS has In the present pilot study, high-frequency TENS
been reported to decrease spasticity and to (100 Hz) applied to the corresponding dermatome
improve voluntary motor control. However, the was used 20 min per day for 4 weeks and the effect
mechanisms mediating these effects are unclear. on electromyographic activity of spastic gastro-
Recent findings suggest that spasticity may be char- soleus muscle was evaluated. Measurements using
acterized more appropriately by a decrease in the an EMG biofeedback apparatus were simpler than
stretch reflex threshold than by an increase in recording H reflex and F waves. The apparatus was
gain.11 used easily by physical therapists, occupational
Several papers reported use of TENS in various therapists, and nurses. Modified Ashworth Scale
forms and frequencies to reduce spasticity, espe- and Ambulation Index were used to evaluate
cially in patients with spinal cord injury and hemi- whether the relaxation was successful or not. TENS
paresis. Sonde et al. treated stroke patients with produced a significant reduction in myoelectrical
low-frequency (1.7 Hz) TENS and reported long- activities in spastic muscles and in the scores of the
term benefits in motor function and activities of Modified Ashworth Scale but not in the Ambulation
daily living. However, the low-frequency TENS did Index.
not reduce either pain or spasticity.12 Han et al. In other studies of TENS, the placebo effect has
treated spasticity of spinal cord origin with TENS of been high. The major limitation of the present
both high (100 Hz) and low (2 Hz) stimulation fre- study was the absence of a control group to exam-

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Armutlu et al.
ine the placebo effect. We felt that we could not
ethically withhold TENS from a placebo group
because patients were coming to our center from
distant parts of the country and had no social secu-
rity or any place to stay during the treatment
period.
A second limitation of our study was not having
evaluated the frequency and severity of pain and
muscle spasms. Despite these 2 important limita-
tions and the failure to demonstrate improvement
in gait, we believe that TENS may prove to be a
useful component of physiotherapy programs for
MS patients because TENS can be used easily and
has no significant side effects. During the treatment
period, only 1 patient developed redness and mild
desquamation under the electrodes.
We conclude that a placebo-controlled study of
TENS with a larger number of patients is warranted.
REFERENCES
1. Matthews WB, ed. McAlpine’s multiple scleroses. New York:
Churchill Livingstone; 1985: 62-101.
2. Surinder P, Brar PT, Marcia B, et al. Evaluation of treatment
protocols on minimal to moderate spasticity in multiple
sclerosis. Arch Phys Med Rehabil 1991;72:186-9.
3. Link A, Kabus C, Haas J. Use of spasmography to assess
the effects of botulinum toxin type A in patients with
lower-limb spasticity. Eur J Neurol 1999;6(suppl 4):69-73.
4. Tekeog*lu Y, Adak B, Goksoy T. Effects of transcutaneous
electrical nerve stimulation (TENS) on Barthel Activities of
82
Downloaded from nnr.sagepub.com at University of Otago Library on March 15, 2015
Daily Living (ADL) index score following stroke. Clin
Rehabil 1998;12(4):277-80.
5. Potisk KP, Gregoric M, Vodovnik L. Effects trancutaneous
electrical nerve stimulation (TENS) on spasticity in patients
with hemiplegia. Scand J Rehabil Med 1995;27:169-74.
6. Goulet C, Arsenault AB, Bourbonnais D, Laramee MT,
Lepage Y. Effects trancutaneous electrical nerve stimulation
on H-reflex and spinal spasticity. Scand J Rehabil Med
1996;28:169-76.
7. Poser CM, Paty DW, Scheinberg LC, et al. New diagnostic
criteria for multiple sclerosis. Guidelines for research pro-
tocol. Ann Neurol 1983;13:227-31.
8. Kurtzke JF. Further notes of disability evaluation in multi-
ple sclerosis, with scale modifications. Neurology
1965;15:654-61.
9. Bohannon RW, Simith MB. Interrater reliability of a modi-
fied Ashworth scale of muscle spasticity. Phys Ther
1987;67:206-7.
10. Hauser SL, Dawson DM, Lehrich JR, et al. Intensive
immunosuppression in progressive multiple sclerosis. A
randomized, three-arm study of high-dose intravenous
cyclophosphamide, plasma exchange, and ACTH. N Engl J
Med 1983;27(308):173-80.
11. Hui-Chan CW, Levin MF. Stretch reflex latencies in spastic
hemiparetic subjects are prolonged after trancutaneous
electrical nerve stimulation. Can J Neurol Sci 1993;20:97-
106.
12. Sonde L, Gip C, Fernaeus SE, Nilsson CG, Viitanen M.
Stimulation with low frequency (1.7Hz) trancutaneous
electrical nerve stimulation (low-tens) increases motor
function of the post-paretic arm. Scand J Rehabil Med
1998;30:95-9.
13. Han JS, Chen XH, Yuan Y, Yan SC. Transcutaneous electri-
cal nerve stimulation for treatment of spinal spasticity.
Chin Med J 1994;107:6-11.
14. Joodaki MR, Olyaei GR, Bagheri H. The effects of electri-
cal nerve stimulation of the lower extremity on H-reflex
and F-wave parameters. Electromyogr Clin Neurophysiol
2001;41(1):23-8.
Neurorehabilitation and Neural Repair 17(2); 2003