The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study

doi:10.21203/rs.3.rs-5013498/v1

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Research Article

The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study

https://doi.org/10.21203/rs.3.rs-5013498/v1

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Background: The aim of our study was to compare the effects of TENS, NMES, and their combined application on posture, functional independence, and spasticity in patients with post-stroke hemiparesis.

Methods: Sixty patients (twenty-six female and thirty-four male), with a mean age of 61.1 years (range, 27 – 81 years) were included in our study. Patients were randomly assigned to one of four treatment groups: TENS, NMES, TENS+NMES, and isolated exercise program. The patients' posture, functional independence, and ankle plantar flexor spasticity were evaluated after 1 month of treatment and at the 4-month follow-up.

Results: Concomitant application of TENS and NMES was more successful in improving posture, functional independence and reducing spasticity at 1 and 4 months follow-up than either application alone. The application of TENS or NMES together with the exercise program provided better results in terms of posture and functional independence at the 1st month. However, it did not achieve a significant difference compared to the exercise program at the 4th month. An exercise program alone was insufficient for reducing spasticity of the ankle plantar flexors. While an additional physical therapy modality (TENS or NMES) was effective in reducing spasticity in the early period, this effect disappeared at the 4th month follow-up and similar results were achieved with an isolated exercise program.

Conclusion: Although TENS or NMES combined with exercise programs achieves successful results immediately after the treatment, it is insufficient after a few months in chronic stroke patients. In concomitant application of TENS and NMES, better results are achieved both after treatment and in a few months of follow-up. Therefore, TENS and NMES should be applied concomitantly.

TENS

NMES

Stroke

Hemiparesis

Exercise program.

Stroke is a cerebrovascular disorder that can lead to permanent disability and a decline in quality of life [1]. Chronic stroke patients often experience decreased balance control, which negatively affects activities of daily living and their ability to walk independently [2, 3]. The most recognized impairments are deficits in motor control and limited mobility. Chronic stroke patients may develop spasticity, which is the main cause of decreased balance and gait. The rate of post-stroke spasticity is 4 - 27% in the 6th week, increasing to 42.6% by the 6th month. Electrical stimulation has been used in numerous studies to decrease spasticity [4].

Electrical stimulation has been widely used in stroke rehabilitation, including transcutaneous nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES). NMES is an effective and conventional therapeutic method for improving motor function in patients with lower extremity paralysis after stroke [5]. During NMES, current pulses are applied to the muscles or motor nerves through surface electrodes to induce muscle contractions to mimic exercise therapy [6]. NMES can help improve muscle strength, joint range of motion, and promote motor relearning. TENS, another electrical stimulation, is used to relieve pain, improve muscle strength and motor function, and reduce spasticity through transdermal output pulses [7]. The motor recovery mechanism of TENS involves the presynaptic inhibition of the hyperactive stretch reflexes in spastic muscles and decreased co-contraction of the spastic antagonist muscles [8].

Numerous studies have investigated the benefits of TENS or NMES applied to the lower extremities. These studies have revealed that both forms of electric stimulation are effective in the recovery of chronic stroke patients [7, 9-11].

However, there is no comparative study on the effect of TENS and NMES applied individually versus their concomitant application. The combined application of TENS and NMES may yield better results. The aim of our study is to compare the effects of TENS and NMES, applied both individually and concomitantly, on posture, lower extremity motor recovery, functional independence, motor function recovery, and spasticity. Our hypothesis is that the concomitant application of TENS and NMES will achieve better results than individually application.

A. Research Design

This was a prospective randomized assessor-blind comparison study designed to compare the effects of individually and concomitant TENS and NMES on posture, functional independence, and spasticity in chronic stroke patients.

B. Ethical Considerations

This study was conducted in accordance with the principles of good clinical and ethical practice and was approved by the Ethics Committee of Gaziosmanpaşa Training and Research Hospital (2022–154). Along with the Declaration of Helsinki, all participants gave written informed consent after being informed about the study´s protocol. [12]. All methods were performed according to relevant guidelines and regulations.

C. Randomization and Blinding

Patients were randomly assigned to one of four groups:

TENS Group: This program included TENS and an exercise program.

NMES Group: This program included NMES and an exercise program.

TENS+NMES Group: This program included both TENS and NMES, along with an exercise program.

Control (Exercise Program) Group: This program included only an exercise program.

Patients were randomly assigned to the four groups using a closed envelope randomization procedure. The physiotherapist opened the envelope 6 hours before the patient began treatment. The same physiotherapist, who was blinded to the group assignments, performed initial evaluation, post-treatment (at 1 month), and 4-month follow-up evaluation.

D. Sample Size Calculation

Gpower 3.1.9.2 software was used to calculate the sample size. In the present study, the mean power was at 0.8, and the alpha error at 0.05. The sample size was calculated based on the Posture Assessment Scale for Stroke Patients from a pilot study [13]. The analysis of Gpower software indicated that at least 14 participants per group would constitute an acceptable sample size; therefore, 68 participants were recruited, accounting for a potential drop-out rate of 20%.

E. Participants

Participants with lower-extremity hemiparesis were recruited from XXXXXX Training and Research Hospital from November 2022 to December 2023.

E.1 Inclusion Criteria:

The criteria of inclusion were (1) first episode of unilateral stroke with hemiparesis caused by hemicerebrum damage; (2) stroke confirmed by CT and/or MRI (3) ability to understand and follow verbal commands; (4) Mini-Mental Scale (MMS) score of 24–30; (5) ablity to independently stand up from a chair, (6) age between 35 to 85 years; (7) no peripheral or central nervous system dysfunction; and (8) ankle dorsiflexion strength of ≤3/5 (Lovett scale).

E.2. Exclusion Criteria:

The criteria for exclusion were (1) cerebellar or brainstem stroke; (2) inability to cooperate with assessment and treatment due to severe cognitive and communication impairment; (3) previous surgical treatment history on the affected extremity; (4) complication with severe heart, lung, liver, kidney, or infectious disease; (5) presence of a cardiac pacemaker; (6) orthopedic disease affecting sit-to-stand movement; (7) contraindications of TENS or NMES: and (8) non-compliance with treatment recommendations or inadequately application.

F. Rehabilitation protocols

F.1. TENS:

Each patient in the TENS group received transcutaneous electrical nerve stimulation (Chattanooga Intellect®, frequency = 100 Hz) for 30 minutes. TENS electrodes were attached over the motor points of the tibialis anterior and quadriceps muscles on the stroke-affected lower extremity. Stimulation was delivered in 200 µs pulses at 100 Hz in the constant mode at the participant’s sensory level, without causing muscle contraction [14]. The tibialis anterior and quadriceps muscles were chosen because they are associated with walking and daily living activities, and because they are superficially located and easily identified. The minimal tingling sensation felt by the patients was defined as the sensory threshold. The patients were asked to inform the physiotherapist if they felt any discomfort or involuntary muscle contraction during TENS. The physiotherapist also observed whether the movement caused by muscle contraction. Stimulation intensity was gradually increased until the patients reported a tingling or buzzing sensation in the tibialis anterior and quadriceps regions, without pain and visible movement [13].

F.2. NMES:

Two dual-channel biofeedback electrical stimulators (Chattanooga Intellect®) were connected to a schedule timer to create a stimulation unit for neuromuscular electrical stimulation in the NMES group. Stimulation was applied via electrodes (5 × 3.5 cm) adhered over the motor points of the tibialis anterior and quadriceps muscles on the paretic extremity. The patients were instructed to relax their paretic extremities during NMES. The waveform of stimulation was a biphasic rectangular wave with a frequency of 30 Hz and a pulse width of 200 μs. The duty cycle was programmed as five seconds on and five seconds off, with a ramp-up and descent time of one second each. This duty cycle was chosen because it could be easily implemented in rehabilitation [13]. Contractions with short pulse durations were preferred in order to prevent central force development during stimulated contractions and limit premature fatigue of the assigned motor units [15]. Stimulation intensity was adjusted to the movement threshold to trigger visible muscle contractions, resulting in partial joint movement.

F.3. Exercise Protocol:

The Patients in all four groups received exercise for 30 minutes once a day, five days a week, during the 4-week treatment period. The patients in the control group did not receive any passive modalities (e.g. electrical stimulation, vibration, ultrasound, heat, or ice) in addition to exercise program. The exercise program session consists of four exercises lasting 30 minutes in total, each completed in 5-10 minutes. These exercises are (1) functional training activities, (2) techniques to facilitate neurodevelopment, (3) active range of motion exercises, and (4) pelvic bridging exercises. The physical therapist monitored the progression of exercises, including increasing the number of repetitions, expanding the range of motion, adjusting the speed of motion, and decreasing the rest time between exercises as the patients' muscle strength improved. Functional training activities based on motor relearning principles were also adjusted and progressed according to the patient's ability.

Electrical stimulation treatment was applied for 30 minutes per session, once a day, five days a week for four weeks in TENS group and NMES group. In the TENS+NMES group, TENS was applied for 30 minutes first, followed by 30 minutes of NMES with a 30-minute interval in between. All patients received exercise program immediately after electrical stimulation session.

A home-based exercise program was prescribed for all groups after one-month treatment period. The content of home exercise program was based on the recommendations from the National Stroke Foundation Clinical Guidelines and included six leg control exercises, six truck control exercises, and four mobility exercises [16]. Home-based exercise programs have been shown to improve lower limb motor functions in patients who have sustained strokes more than one year previously. Combining TENS with home-based exercise programs has been found to decrease plantar flexor spasticity, improve ankle dorsi flexor and plantar flexor strength, and significantly increase gait velocity more than TENS alone [17].

G. Evaluation

The same physiotherapist who performed the functional evaluations was blinded to group allocation at baseline, post-treatment, and 4^th month follow-up.

Disability caused by stroke was evaluated using the National Institutes of Health Stroke Scale (NIHSS). The following domains were assessed with the NIHSS: level of consciousness, eye movements, integrity of visual fields, facial movements, arm and leg muscle strength, sensation, coordination, language, speech and neglect. Evaluation was based on a total score ranging from 0 to 42, with higher the scores indicating more severe stroke [18].

The lower extremity motor recovery was assessed using Brunnstrom's Hemiplegia Recovery Staging. There are six grades in Brunnstrom's Hemiplegia Recovery Staging for the lower extremity. A higher stage indicates better motor function. The Brunnstrom stages were preferred because they reflect the underlying motor control based on clinical assessment of movement quality [19].

Postural Assessment Scale for Stroke Patients (PASS) was developed specifically for evaluating balance in stroke patients [20]. PASS contains two subheadings for evaluating balance: maintaining posture (static PASS) and changing posture (dynamic PASS). It consists of 12 items to evaluate balance: 5 items (sitting without support; standing with support; standing without support; standing on the non-paretic leg; standing on the paretic leg) for static PASS, and 7 items (supine to affected side lateral; supine to non-affected side lateral; supine to sitting up on the edge of the mat; sitting on the edge of the mat to supine; sitting to standing; standing to sitting down; standing, picking up a pencil from the floor) for dynamic PASS. Evaluation was based on a total score ranging from 0 to 36, with higher the scores indicating more favorable balance in stroke patients [21].

Functional Independence Measures (FIM) is widely used to assess the independence of stroke patients. It contains 18 items under the following categories: self-care, sphincter control, transfers, locomotion, communication and social cognition. Each item was scored from 1 to 7, with 7 indicating complete independence and 1 indicating complete dependence. Scores below 6 indicate that the patient requires assistance or supervision from another person [19].

The Modified Ashworth Scale (MAS) was used to assess the spasticity of the ankle plantar flexors. The physiotherapist passively moved the ankle from maximal plantarflexion to maximal dorsiflexion. The MAS assigns a grade of spasticity on a scale of 0-4 based on the level of resistance in response to passive movement. A score of 0 represents no increase in muscle tone, while a score of 4 represents rigidity of the affected part in flexion or extension [22].

H. Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows (Version 15.0; SPSS Inc., Chicago, IL). The data were first evaluated for normality using the Shapiro–Wilk test and were transformed when necessary to meet the assumption of normal distribution. Descriptive statistics were used for relevant characteristics of the patients. Baseline and 4^th month follow-up measures were analyzed using two-way repeated measures analysis of variance (ANOVA) with the independent factors of time and group. For categorical secondary outcome measures, a chi-square test or Fisher’s exact test was used, with the results not corrected for multiple testing. All demographic and quantitative data are expressed as mean ± SD. Differences were considered statistically significant at P-values < 0.05.

Sixty-eight patients with post-stroke hemiparesis were included in our study. Eight patients were excluded during the follow-up period: four patients did not attend the follow-up, one patient experienced a myocardial infarction, one patient suffered a proximal femur fracture, one patient underwent knee joint surgery, and one patient discontinued the rehabilitation in the 3rd week. Sixty patients were evaluated after treatment and at the 4th month follow-up (Fig. 1). No side effects were observed in any of the patients after rehabilitation.

Twenty-six female and thirty-four male, with a mean age of 61.1 years (range, 27–81 years) were included in our study. There were no significant differences in age, sex, body mass index, type of stroke, location of stroke, affected side, and time to initial intervention between the groups (P > 0.05), (Table 1).

Table 1

Demographic characteristics of the groups.
Group	TENS	NMES	TENS + NMES	Control	P
Age	66.0 ± 10.1	60.8 ± 13.1	56.6 ± 17.3	61.0 ± 8.9	0.267^a
Gender (M/F)	11/4	10/5	7/8	6/9	0.247^b
BMI	26.3 ± 3.7	25.8 ± 2.7	27.7 ± 4.8	28.2 ± 4.6	0.333^a
Type of stroke (infarction/hemorrhage)	9/6	10/5	10/5	12/3	0.690^b
Location of stroke (cortical/subcortical)	12/3	10/5	12/3	11/4	0.806^b
Affected side (Right/Left)	6/9	9/6	9/6	8/7	0.657^b
Post-stroke months (time to initial intervention)	12.4 ± 6.8	15.7 ± 8.8	13.8 ± 5.4	16.8 ± 7.6	0.367^a
BMI: Body Mass Index, F: Female, M: Male, TENS: transcutaneous nerve stimulation;
NMES: neuromuscular electrical stimulation; SR: standard Rehabilitation; ANOVA: analysis of variance.
^a Using ANOVA test.
^b Using a chi-square test.

A. Pre-treatment Evaluation:

There was no significant difference between the groups in terms of balance, functional independence, the lower extremity motor staging, the spasticity of the ankle plantar flexors, disability caused by stroke (P > 0.05), (Table 2).

Table 2

Initial values of the groups.
Group	TENS	NMES	TENS + NMES	Control	P
Initial NIHSS scores	7.2 ± 2.9	7.8 ± 3.4	6.0 ± 3.2	5.6 ± 2.7	0.191^a
Initial Brunnstrom stage-affected lower limb (I/II/III/ IV/V)	4/5/4/2	4/3/7/1	3/6/5/1	3/4/6/2	0.965^b
Initial PASS scores	13.9 ± 5.7	15.3 ± 6.6	15.4 ± 4.9	12.0 ± 5.5	0.345^a
Initial FIM scores	62.1 ± 20.1	65.7 ± 16.2	67.1 ± 23.3	57.4 ± 15.2	0.514^a
Initial MAS scores	2.7 ± 0.7	2.6 ± 0.8	2.8 ± 0.6	2.7 ± 0.6	0.966^a
^a Using ANOVA test.
^b Using Chi-square test.
NIHSS: National Institutes of Health Stroke Scale; PASS: Postural Assessment Scale for Stroke; FIM: Functional Independence Measure; MAS: Modified Ashworth Scale

B. Post-treatment Evaluation:

B.1. First Month Assessment

According to the PASS and FIM scores, the best results were observed in the TENS + NMES group, while the worst results were found in the control group. There was no significant difference between the TENS and NMES groups (P > 0.05), (Table 3). Both groups showed better results than the control group but worse results than the TENS + NMES group (P < 0.001), (Table 3). The spasticity of the ankle plantar flexors in the TENS + NMES group was significantly better than in the other three groups according to the MAS (P < 0.001), (Table 3). There was no significant difference in MAS score between the TENS, NMES and the control groups (P > 0.05), (Table 3).

Table 3

Initial, 1st and 4th month values of the groups.
Group	TENS	NMES	TENS + NMES	Control	P
① PASS scores	13.9 ± 5.7	15.3 ± 6.6	15.4 ± 4.9	12.0 ± 5.5	0.345^a
② PASS scores	19.5 ± 5.0	20.1 ± 5.6	25.3 ± 4.4	14.3 ± 4.9	< 0.001^a
③ PASS scores	20.6 ± 4.6	21.0 ± 5.4	26.4 ± 4.6	19.1 ± 4.1	< 0.001^a
P	0.002^a	0.025^a	< 0.001^a	0.001^a
① FIM scores	62.1 ± 20.1	65.7 ± 16.2	67.1 ± 23.3	57.4 ± 15.2	0.514^a
② FIM scores	78.0 ± 14.4	79.3 ± 12.1	92.4 ± 12.8	64.4 ± 14.1	< 0.001^a
③ FIM scores	84.0 ± 16.7	86.6 ± 11.6	99.7 ± 12.1	75.0 ± 12.5	< 0.001^a
P	0.003^a	< 0.001^a	< 0.001^a	0.005^a
① MAS scores	2.7 ± 0.7	2.6 ± 0.8	2.8 ± 0.6	2.7 ± 0.6	0.966^a
② MAS scores	1.8 ± 0.6	1.7 ± 0.4	1.0 ± 0.6	2.4 ± 0.6	< 0.001^a
③ MAS scores	2.0 ± 0.5	2.0 ± 0.7	1.1 ± 0.4	2.2 ± 0.6	0.001^a
P	0.023^a	0.031^a	< 0.001^a	0.260^a
① : Initial scores ② : 1st month scores ③ : 4th month follow-up scores.

B.2. Fourth Month Assessment

The PASS, FIM, and MAS scores of the TENS + NMES group were significantly better than the other three groups (P < 0.001), (Table 3). There was no significant difference between the between TENS, NMES and the control groups (P > 0.05), (Table 3).

C. Individual Evaluation of each groups:

C.1. The Postural and Functional Independence Assessment:

TENS, NMES, and TENS + NMES Groups

After treatment, all three treatments showed significant improvements in balance and functional independence compared to pre-treatment. The PASS and FIM scores at the 1st and 4th months were significantly better than pre-treatment (P < 0.05), (Table 3). No significant difference was found between the results at the 1st month and the 4th month (P > 0.05), (Table 3).

Control Group

After treatment, no significant improvement in balance and functional independence was found at the 1st month follow-up compared to pre-treatment (P > 0.05), (Table 3). However, the PASS and FIM scores at the 4th month follow-up was found to be significantly better than pre-treatment (P < 0.05), (Table 3).

C.2. The Spasticity of the Ankle Plantar Flexors Assessment:

TENS and NMES Groups

After treatment, a significant improvement in the spasticity of the ankle plantar flexors was observed. The results at 1st month were significantly better than pre-treatment (P < 0.05), (Table 3), but no significant difference was found at the 4th month (P > 0.05), (Table 3). The improvement in spasticity of the ankle plantar flexors achieved after treatment was not maintained at the 4th month.

TENS + NMES Group

After treatment, a significant improvement in the spasticity of the ankle plantar flexors was observed. The results at the 1st and 4th months were significantly better than pre-treatment (P < 0.05), (Table 3). No significant difference was detected between the results at the 1st month and the 4th month (P > 0.05), (Table 3).

Control Group

The effect of isolated exercise on the spasticity of the ankle plantar flexors was found to be insufficient. No significant changes were observed in the results at the 1st and 4th months compared to pre-treatment (P > 0.05) (Table 3).

All four-treatment options significantly improved posture and functional independence at the 4th month follow-up compared to pre-treatment. Although the application of TENS or NMES along with exercise program result in better outcomes in terms of posture and functional independence at the 1st month, it does not create a significant difference compared to an isolated exercise program at the 4th month. The combination of TENS + NMES with exercise programs is more successful in improving posture and functional independence than the other three- treatment options at 1st month and 4th month follow-ups.

An exercise program alone is insufficient for treating spasticity of the ankle plantar flexors. An additional physical therapy modality is needed to reduce spasticity. In terms of spasticity of the ankle plantar flexors, adding TENS or NMES to the exercise program provides significant improvement at the 1st month follow-up, but has no significant effect at the 4th follow-up. While TENS or NMES applications along with exercise program reduce spasticity in the early period, this benefit disappears at the 4th month follow-up. The TENS + NMES treatment reduces the spasticity of the ankle plantar flexors at the 1st month, and unlike the other treatments, this reduction in spasticity is maintained at the 4th month.

Postural abnormality and post-stroke spasticity contribute to disorders and disabilities that negatively affect functional recovery and lead to a decrease in quality of life [10]. TENS and NMES have been shown to be effective in improving posture, spasticity and functional independence in stroke patients [23, 24]. TENS or NMES, in addition to exercise programs, leads to greater improvements in posture, spasticity, and functional independence [24, 25].

TENS parameters used in studies on stroke treatments vary between 1.7–100 Hz frequency, session duration between 15 and 60 minutes, and number of sessions between 1 and 30 [23]. The use of different parameters is rarely justified and is often based on parameters used in previous studies. There is no consensus on standardized parameters and protocols for the use of TENS in stroke treatments. In our study, we applied TENS at a frequency of 100 Hz for 30 minutes per day for 4 weeks, following the approach used in most studies in the literature [7].

There are various studies on the duration and frequency of NMES application, but no consensus has been reached on the optimal duration and frequency. We preferred the 30-minute period used in most studies in the literature. We preferred low frequency because high-frequency NMES application can sometimes lead to muscle fatigue and a decrease in contraction strength, which can increase the muscle tone of the affected limbs [10, 26].

Home-based rehabilitation programs are effective lower extremity rehabilitation, increase muscle strength, and improve gait velocity in individuals with chronic stroke [17]. Hospital-based rehabilitation is superior to home-based rehabilitation in improving outcomes [27]. Therefore, we did not apply the isolated home-based rehabilitation program to patients alone. Our study revealed that home-based rehabilitation program is also effective in enhancing the success of patient treatment after discharge and in preventing the loss of improvements gained during hospital-based rehabilitation.

While studies in the literature have shown that TENS or NMES along with exercise program yields better results than an isolated exercise program, these results were typically evaluated immediately after the end of the treatment, with later outcomes not being assessed. In our study, similar to the literature, TENS or NMES combined with an exercise program yielded better results compared to an isolated exercise program. However, there was no significant difference in outcomes at the 4th month follow-up. On the other hand, TENS + NMES demonstrated better results at the 4th month than both an isolated exercise program and TENS or NMES combine with exercise [10, 23].

TENS or NMES combined with an isolated exercise program does not affect mid-term posture, spasticity, and functional outcomes in post-stroke hemiparesis. Although isolated TENS or NMES applications have a positive effect on early (1-month) outcomes, they do not affect mid-term (4-month) outcome. For better mid-term results in posture, spasticity, and functional outcomes, TENS + NMES should be applied combined with isolated exercise program.

Limitation of Study

Since a home-based rehabilitation program was applied to all patients after discharge, the effectiveness of the program could not be compared. If a home-based rehabilitation program had not been applied to a different group after discharge, its effectiveness could have been comparable.

Although the positive effect of TENS + NMES application combined with an isolated exercise was demonstrated at the 4th month, its effect in the later period could not be demonstrated. It would be beneficial to essess whether this positive effect is permanent or a temporary with longer-term follow-up in future studies. Extending the follow-up period could help in assessing the sustainability of the treatment effects.

Acknowledgements

The authors wish to thank the patients for their participation in this study. They extend their gratitude to the Rehabilitation Department physiotherapist team at Gaziosmanpaşa Training and Research Hospital, as well as to Ebru Yılmaz Yalçınkaya.

Author contributions

BB and AÖF conceptualised the review, created aims and established inclusion and exclusion criteria. AÖF performed assessment for the risk of bias and wrote the initial draft. BB contributed to reviewing and editing. All authors were involved in interpreting the data, critically revising the manuscript, and approve the final version for publication.

Funding

There are no financial supports.

Data Availability

The data used to support the findings of this study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

All participants achieved written information and informed consent was obtained. The study was approved by the Ethics Committee of Gaziosmanpaşa Training and Research Hospital (2022–154) and the investigation conforms to the principles outlined in the Declaration of Helsinki [12].

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study

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Abstract

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Introduction

Materials & methods

Results

A. Pre-treatment Evaluation:

B. Post-treatment Evaluation:

C.1. The Postural and Functional Independence Assessment:

C.2. The Spasticity of the Ankle Plantar Flexors Assessment:

Discussion

Conclusion

Limitation of Study

Declarations

References

Additional Declarations

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Version 1