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

The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study Betül Başar, Ömer Faruk Alp This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5013498/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2025 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted 4 You are reading this latest preprint version Abstract 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. Figures Figure 1 Introduction 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. Materials & methods 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. Results 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 0.05), (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 0.05), (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 ). 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 ). 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 ). 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 ). Discussion 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 ]. Conclusion 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. Declarations 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. References Shen Y, Chen L, Zhang L, Hu S, Su B, Qiu H, et al. Effectiveness of a novel contralaterally controlled neuromuscular electrical stimulation for restoring lower limb motor performance and activities of daily living in stroke survivors: A randomized controlled trial. Neural Plast. 2022; 11: 2022:5771634. https://doi.org/ 10.1155/2022/5771634. PMID: 35069728; PMCID: PMC8767388. 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Large involuntary forces consistent with plateau-like behavior of human motoneurons. J Neurosci 2001;21(11): 4059–4065. https://doi.org/10.1523/JNEUROSCI.21-11-04059.2001. PMID: 11356893; PMCID: PMC6762712. Chung BPH, Chiang WKH, Lau H, Lau TFO, Lai CWK, Sit CSY. Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: A single-blind randomized controlled trial. Hong Kong Physiother J. 2020;40(1):63-73. https://doi.org/10.1142/S1013702520500079. PMID: 32489241; PMCID: PMC7136530. Hui-Chan CWY, Ng SSM, Mak MKY. Effectiveness of a home-based rehabilitation programme on lower limb functions after stroke. Hong Kong Med J. 2009;15:42-46. PMID: 19509438 Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61. https://doi.org/10.1016/j.jphys.2013.12.012. PMID: 24856948. Eser F, Yavuzer G, Karakus D, Karaoglan B. The effect of balance training on motor recovery and ambulation after stroke: a randomized controlled trial. Eur J Phys Rehabil Med. 2008;44(1):19-25. PMID: 18385624. Barranco CE, Cuerda RCLC, Porras VA, Rueda FM. Postural Assessment Scale for Stroke Patients in Acute, Subacute and Chronic Stage: A Construct Validity Study. Diagnostics (Basel). 2021;21;11(2):365. https://doi.org/10.3390/diagnostics11020365. PMID: 33670068; PMCID: PMC7927023. Huang YC, Wang WT, Liou TH, Liao CD, Lin LF, Huang SW. Postural Assessment Scale for Stroke Patients Scores as a predictor of stroke patient ambulation at discharge from the rehabilitation ward. J Rehabil Med. 2016;48(3):259-264. https://doi.org/10.2340/16501977-2046. PMID: 26667386. Vidmar T, Kregar N G, Puh U. Reliability of the modified ashworth scale after stroke for 13 muscle groups. Arch Phys Med Rehabil. 2023;104(10):1606-1611. https://doi.org/10.1016/j.apmr.2023.04.008. PMID: 37121531. Mahmood A, Veluswamy SK, Hombali A, Mullick A, Manilandan N, Solomon JM. Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2019;100(4):751-768. https://doi.org/10.1016/j.apmr.2018.10.016. PMID: 30452892. Choi Y, Lee S, Kim M, Chang W. Effects of Neuromuscular Electrical Stimulation with Gastrocnemius Strengthening on Foot Morphology in Stroke Patients: A Randomized Controlled Trial. Healthcare (Basel). 2024; 12(7): 777. https://doi.org/10.3390/healthcare12070777. PMID: 38610199; PMCID: PMC11011460. Jung KS , In TS, Cho HY. 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. https://doi.org/10.1016/j.gaitpost.2017.03.007. PMID: 28324754. Lee YY, Lin KC, Cheng HJ, Wu CY, Hsieh YW, Chen CK. Effects of combining robot-assisted therapy with neuromuscular electrical stimulation on motor impairment, motor and daily function, and quality of life in patients with chronic stroke: a double-blinded randomized controlled trial. J Neuroeng Rehabil. 2015, 12:96. https://doi.org/10.1186/s12984-015-0088-3. PMID: 26520398; PMCID: PMC4628254. Gelaw AY, Janakiraman B, Gebremeskel BF, Ravichandran H. Effectiveness of Home-based rehabilitation in improving physical function of persons with Stroke and other physical disability: A systematic review of randomized controlled trials. J Stroke Cerebrovasc Dis. 2020;29(6):104800. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104800. PMID: 32278534. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2025 Read the published version in BMC Sports Science, Medicine and Rehabilitation → Version 1 posted Editorial decision: Revision requested 09 Sep, 2024 Editor assigned by journal 03 Sep, 2024 Submission checks completed at journal 03 Sep, 2024 First submitted to journal 01 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5013498","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":351518949,"identity":"415b3c1b-6cdc-43cf-b2e1-fa43d25257c0","order_by":0,"name":"Betül Başar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYBACAxDxgCEBwuNhYJAzgIhb4NHCzADUgNBiDBZhMJAgXkviBrAWBtxazNn7j0kk1KTJm89IfvbhTc299O3s/Uc3/CiQYOBv707ApsWy5zCbRMKxHMM5N9KMZ845Vpy7EyhyswfoMIkzZzdgddiNZKAWtgrGGTwHjJl52BJyNwBFbvAAtRhI5GLXcv8xUMu/CvsZPMc/M/P8S0gHGXLzDz4tN5jZJBLbchJnsPcYM/O2JSSAtNzGZ4tlT7KxRWJfWjJQSzHj3L4Eww1nDpvdljGQ4MHlF3P2gw9vfPiWbDuDmX0zw5tvCfIGxxuf3Xzzx0aOv70XqxbcgIc05aNgFIyCUTAKkAEAN4pgUsk/stEAAAAASUVORK5CYII=","orcid":"","institution":"Gaziosmanpaşa Eğitim Ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Betül","middleName":"","lastName":"Başar","suffix":""},{"id":351518950,"identity":"578336a9-c910-4a35-8e29-1d20bfcb9816","order_by":1,"name":"Ömer Faruk Alp","email":"","orcid":"","institution":"Gaziosmanpaşa Eğitim Ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"Ömer","middleName":"Faruk","lastName":"Alp","suffix":""}],"badges":[],"createdAt":"2024-09-01 15:06:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5013498/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5013498/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13102-025-01155-w","type":"published","date":"2025-04-24T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67090853,"identity":"18299129-0b03-4686-873f-9ba1c54c4668","added_by":"auto","created_at":"2024-10-21 06:47:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":128117,"visible":true,"origin":"","legend":"\u003cp\u003eThe flow chart for patient recruitment and follow-up.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5013498/v1/7d9286feebde6905ec6ebab8.png"},{"id":81569526,"identity":"6d84ab37-686b-4972-b5bc-f8347f200822","added_by":"auto","created_at":"2025-04-28 16:05:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1217712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5013498/v1/f19f605f-a4c6-4057-8dc3-747de5099466.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStroke is a cerebrovascular disorder that can lead to permanent disability and a decline in quality of life\u0026nbsp;[1].\u0026nbsp;Chronic stroke patients often experience decreased balance control, which negatively affects activities of daily living and their ability to walk independently\u0026nbsp;[2, 3].\u0026nbsp;The most recognized impairments are deficits in motor control and limited mobility.\u0026nbsp;Chronic stroke patients may develop spasticity,\u0026nbsp;which is the main cause of decreased balance and gait.\u0026nbsp;The rate of post-stroke spasticity is 4 - 27% in the 6th week, increasing to 42.6% by the 6th month.\u0026nbsp;Electrical stimulation has been used in numerous studies to decrease spasticity\u0026nbsp;[4].\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eElectrical 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\u0026nbsp;[5].\u0026nbsp;During NMES, current pulses are applied to the muscles or motor nerves through surface electrodes to induce muscle contractions to mimic exercise therapy\u0026nbsp;[6].\u0026nbsp;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\u0026nbsp;[7].\u0026nbsp;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\u0026nbsp;[8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumerous 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\u0026nbsp;[7, 9-11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, 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.\u003c/p\u003e"},{"header":"Materials \u0026 methods","content":"\u003cp\u003e\u003cstrong\u003eA. Research Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a prospective randomized assessor-blind comparison study designed to\u0026nbsp;compare\u0026nbsp;the effects of individually and concomitant TENS and NMES on posture, functional independence,\u0026nbsp;and spasticity in chronic stroke patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Ethical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of good clinical and ethical practice and was approved\u0026nbsp;by the Ethics Committee of Gaziosmanpaşa Training and Research Hospital (2022–154). \u0026nbsp;Along with the Declaration of Helsinki, all participants gave written informed consent after being informed about the study´s protocol.\u0026nbsp;[12].\u0026nbsp;All methods were performed according to relevant guidelines and regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC. Randomization and Blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were randomly assigned to one of four groups:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTENS Group:\u0026nbsp;\u003c/strong\u003eThis program included TENS and an exercise program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNMES Group:\u003c/strong\u003e This program included NMES and an exercise program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTENS+NMES Group:\u003c/strong\u003e This program included both TENS and NMES, along with an exercise program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl (Exercise Program) Group:\u003c/strong\u003e This program included only an exercise program.\u003c/p\u003e\n\u003cp\u003ePatients were randomly assigned to the four groups using a closed envelope randomization procedure. The\u0026nbsp;physiotherapist opened the envelope 6 hours before the patient began treatment.\u0026nbsp;The same physiotherapist, who was blinded to the group assignments, performed initial evaluation, post-treatment (at 1 month), and 4-month follow-up evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD. Sample Size Calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGpower 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\u0026nbsp;[13].\u0026nbsp;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%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE. Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants with lower-extremity hemiparesis were recruited from XXXXXX Training and Research Hospital from November 2022 to December 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE.1 Inclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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\u0026nbsp;commands; (4) Mini-Mental Scale (MMS) score of 24–30;\u0026nbsp;(5)\u0026nbsp;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).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE.2. Exclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe criteria for exclusion were (1) cerebellar or brainstem stroke; (2) inability to cooperate with assessment and treatment due to severe cognitive and communication impairment;\u0026nbsp;(3)\u0026nbsp;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF. Rehabilitation protocols\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF.1. TENS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach 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\u0026nbsp;pulses at 100 Hz in the constant mode at the participant’s sensory level, without causing muscle contraction\u0026nbsp;[14].\u0026nbsp;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\u0026nbsp;[13].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF.2. NMES:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;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.\u0026nbsp;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\u0026nbsp;[13].\u0026nbsp;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\u0026nbsp;[15].\u0026nbsp;Stimulation intensity was adjusted to the movement threshold to trigger visible muscle contractions, resulting in partial joint movement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF.3. Exercise Protocol:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eElectrical 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.\u0026nbsp;All patients received exercise program immediately after electrical stimulation session.\u003c/p\u003e\n\u003cp\u003eA 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 \u0026nbsp;included six leg control exercises, six truck control exercises, and four mobility exercises\u0026nbsp;[16].\u0026nbsp;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\u0026nbsp;[17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eG. Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe same physiotherapist who performed the functional evaluations was blinded to group allocation at baseline, post-treatment, and 4\u003csup\u003eth\u003c/sup\u003e month follow-up.\u003c/p\u003e\n\u003cp\u003eDisability 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\u0026nbsp;[18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 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\u0026nbsp;[19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostural Assessment Scale for Stroke Patients (PASS) was developed specifically for evaluating balance in stroke patients\u0026nbsp;[20].\u0026nbsp;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\u0026nbsp;[21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunctional 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\u0026nbsp;that the patient requires assistance or supervision from another person\u0026nbsp;[19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 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 \u0026nbsp;maximal dorsiflexion.\u0026nbsp;The MAS assigns a grade of spasticity on a scale of 0-4 based\u0026nbsp;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\u0026nbsp;[22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eH. Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical 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\u003csup\u003eth\u003c/sup\u003e 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 \u0026lt; 0.05. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSixty-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.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No side effects were observed in any of the patients after rehabilitation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTwenty-six female and thirty-four male, with a mean age of 61.1 years (range, 27\u0026ndash;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\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTENS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTENS\u0026thinsp;+\u0026thinsp;NMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.6\u0026thinsp;\u0026plusmn;\u0026thinsp;17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender (M/F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.247\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.333\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of stroke (infarction/hemorrhage)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.690\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation of stroke (cortical/subcortical)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.806\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffected side (Right/Left)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.657\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-stroke months (time to initial intervention)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.367\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eBMI\u003c/b\u003e: Body Mass Index, \u003cb\u003eF\u003c/b\u003e: Female, \u003cb\u003eM\u003c/b\u003e: Male, \u003cb\u003eTENS\u003c/b\u003e: transcutaneous nerve stimulation;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNMES\u003c/b\u003e: neuromuscular electrical stimulation; \u003cb\u003eSR\u003c/b\u003e: standard Rehabilitation; \u003cb\u003eANOVA\u003c/b\u003e: analysis of variance.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Using ANOVA test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Using a chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eA. Pre-treatment Evaluation:\u003c/h2\u003e \u003cp\u003eThere 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\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInitial values of the groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTENS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTENS\u0026thinsp;+\u0026thinsp;NMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial NIHSS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.191\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial Brunnstrom stage-affected lower limb (I/II/III/ IV/V)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/5/4/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/3/7/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/6/5/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3/4/6/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.965\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial PASS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.345\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial FIM scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.514\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial MAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.966\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Using ANOVA test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003eb\u003c/sup\u003e Using Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNIHSS\u003c/b\u003e: National Institutes of Health Stroke Scale; \u003cb\u003ePASS\u003c/b\u003e: Postural Assessment Scale for Stroke; \u003cb\u003eFIM\u003c/b\u003e: Functional Independence Measure; \u003cb\u003eMAS\u003c/b\u003e: Modified Ashworth Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eB. Post-treatment Evaluation:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eB.1. First Month Assessment\u003c/strong\u003e \u003cp\u003eAccording to the PASS and FIM scores, the best results were observed in the TENS\u0026thinsp;+\u0026thinsp;NMES group, while the worst results were found in the control group. There was no significant difference between the TENS and NMES groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Both groups showed better results than the control group but worse results than the TENS\u0026thinsp;+\u0026thinsp;NMES group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The spasticity of the ankle plantar flexors in the TENS\u0026thinsp;+\u0026thinsp;NMES group was significantly better than in the other three groups according to the MAS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There was no significant difference in MAS score between the TENS, NMES and the control groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInitial, 1st and 4th month values of the groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTENS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTENS\u0026thinsp;+\u0026thinsp;NMES\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e① PASS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.345\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e② PASS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e③ PASS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e① FIM scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;23.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.514\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e② FIM scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e③ FIM scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.0\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e① MAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.966\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e② MAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e③ MAS scores\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.260\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003e①\u003c/b\u003e : Initial scores \u003cb\u003e②\u003c/b\u003e : 1st month scores \u003cb\u003e③\u003c/b\u003e : 4th month follow-up scores.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eB.2. Fourth Month Assessment\u003c/strong\u003e \u003cp\u003eThe PASS, FIM, and MAS scores of the TENS\u0026thinsp;+\u0026thinsp;NMES group were significantly better than the other three groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). There was no significant difference between the between TENS, NMES and the control groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eC.\u003c/b\u003e \u003cb\u003eIndividual Evaluation of each groups\u003c/b\u003e:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eC.1. The Postural and Functional Independence Assessment:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eTENS, NMES, and TENS\u0026thinsp;+\u0026thinsp;NMES Groups\u003c/strong\u003e \u003cp\u003eAfter 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\u0026thinsp;\u0026lt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No significant difference was found between the results at the 1st month and the 4th month (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eControl Group\u003c/strong\u003e \u003cp\u003eAfter treatment, no significant improvement in balance and functional independence was found at the 1st month follow-up compared to pre-treatment (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, the PASS and FIM scores at the 4th month follow-up was found to be significantly better than pre-treatment (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eC.2. The Spasticity of the Ankle Plantar Flexors Assessment\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eTENS and NMES Groups\u003c/strong\u003e \u003cp\u003eAfter 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\u0026thinsp;\u0026lt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), but no significant difference was found at the 4th month (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The improvement in spasticity of the ankle plantar flexors achieved after treatment was not maintained at the 4th month.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTENS\u0026thinsp;+\u0026thinsp;NMES Group\u003c/strong\u003e \u003cp\u003eAfter 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\u0026thinsp;\u0026lt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No significant difference was detected between the results at the 1st month and the 4th month (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eControl Group\u003c/strong\u003e \u003cp\u003eThe 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\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAll 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\u0026thinsp;+\u0026thinsp;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.\u003c/p\u003e \u003cp\u003eAn 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\u0026thinsp;+\u0026thinsp;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.\u003c/p\u003e \u003cp\u003ePostural abnormality and post-stroke spasticity contribute to disorders and disabilities that negatively affect functional recovery and lead to a decrease in quality of life [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. TENS and NMES have been shown to be effective in improving posture, spasticity and functional independence in stroke patients [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. TENS or NMES, in addition to exercise programs, leads to greater improvements in posture, spasticity, and functional independence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTENS parameters used in studies on stroke treatments vary between 1.7\u0026ndash;100 Hz frequency, session duration between 15 and 60 minutes, and number of sessions between 1 and 30 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere 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 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHome-based rehabilitation programs are effective lower extremity rehabilitation, increase muscle strength, and improve gait velocity in individuals with chronic stroke [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hospital-based rehabilitation is superior to home-based rehabilitation in improving outcomes [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eWhile 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\u0026thinsp;+\u0026thinsp;NMES demonstrated better results at the 4th month than both an isolated exercise program and TENS or NMES combine with exercise [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTENS 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\u0026thinsp;+\u0026thinsp;NMES should be applied combined with isolated exercise program.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitation of Study\u003c/h2\u003e \u003cp\u003eSince 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.\u003c/p\u003e \u003cp\u003eAlthough the positive effect of TENS\u0026thinsp;+\u0026thinsp;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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the patients for their participation in this study.\u0026nbsp;They extend their gratitude to the Rehabilitation Department physiotherapist team at Gaziosmanpaşa Training and Research Hospital, as well as to Ebru Yılmaz Yal\u0026ccedil;ınkaya.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBB and A\u0026Ouml;F conceptualised the review, created aims and established inclusion and exclusion criteria. A\u0026Ouml;F 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no\u0026nbsp;financial\u0026nbsp;supports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants achieved written information and informed consent was obtained. The study was approved by\u0026nbsp;the Ethics Committee of Gaziosmanpaşa Training and Research Hospital (2022\u0026ndash;154)\u0026nbsp;and the investigation conforms to the principles outlined in the Declaration of Helsinki [12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eShen Y, Chen L, Zhang L, Hu S, Su B, Qiu H, et al. Effectiveness of a novel contralaterally controlled neuromuscular electrical stimulation for restoring lower limb motor performance and activities of daily living in stroke survivors: A randomized controlled trial. Neural Plast. 2022; 11: 2022:5771634. https://doi.org/ 10.1155/2022/5771634. PMID: 35069728; PMCID: PMC8767388.\u003c/li\u003e\n \u003cli\u003eNindorera F, Nduwimana I, Thonnard J L, Kossi O. Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials. Disabil Rehabil. 2022;44(15):3760-3771. https://doi.org/ 10.1080/09638288.2021.1894247. PMID: 33715555\u003c/li\u003e\n \u003cli\u003ePark 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;10:20:1890-1896. https://doi.org/10.12659/MSM.890926. PMID: 25300431; PMCID: PMC4206395\u003c/li\u003e\n \u003cli\u003eBrusola G, Garcia E, Albosta M, Daly A, Kafes K, Furtado M. Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review. NeuroRehabilitation. 2023;52(3):349-363. https://doi.org/10.3233/NRE-220275. PMID: 36806522\u003c/li\u003e\n \u003cli\u003eHong Z, Sui M, Zhuang Z, Liu H, Zheng X, Cai C, et al. Effectiveness of neuromuscular electrical stimulation on lower limbs of patients with hemiplegia after chronic stroke: A systematic review. Arch Phys Med Rehabil. 2018;99(5):1011-1022. https://doi.org/10.1016/j.apmr.2017.12.019. PMID: 29357280\u003c/li\u003e\n \u003cli\u003eNussbaum EL, Houghton P, Anthony J, Rennie S, Shay BL, Hoens AM. Neuromuscular electrical stimulation for treatment of muscle impairment: Critical review and recommendations for clinical practice. Physiother Can. 2017;69(5):1-76. https://doi.org/10.3138/ptc.2015-88. PMID: 29162949; PMCID: PMC5683854\u003c/li\u003e\n \u003cli\u003eMarcolino MAZ, Hauck M, Stein C, Schardong J, Pagnussat AAS, Plentz RDM. \u003csup\u003e\u0026nbsp;\u003c/sup\u003eEffects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials. Disabil Rehabil. 2020;42(5):623-635. https://doi.org/10.1080/09638288.2018.1503736. PMID:30326752\u003c/li\u003e\n \u003cli\u003eKwong PW, Ng GY, Chung RC, Ng SS. Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysis. Clin Rehabil. 2018;32(9):1203-1219. https://doi.org/10.1177/0269215517745349. PMID: 29232981.\u003c/li\u003e\n \u003cli\u003eKristensen MGH, Busk H, Wienecke T. \u003csup\u003e\u0026nbsp;\u003c/sup\u003eNeuromuscular electrical stimulation improves activities of daily living post stroke: A systematic review and meta-analysis. Arch Rehabil Res Clin Transl. 2021;12;4(1):100167. https:/doi.org/10.1016/j.arrct.2021.100167. PMID: 35282150; PMCID: PMC8904887.\u003c/li\u003e\n \u003cli\u003eChasiotis A, Giannopapas V, Papadopoulou M, Chondrogianni M, Stasinopoulos D, Giannopoulos S, et al. The effect of neuromuscular electrical nerve stimulation in the management of post-stroke spasticity: A scoping review. Cureus. 2022;29;14(11):e32001. https://doi.org/10.7759/cureus.32001. PMID: 36600817; PMCID: PMC9800032.\u003c/li\u003e\n \u003cli\u003eIn TS, Jung JH, Jung KS, Cho HY. Effectiveness of transcutaneous electrical nerve stimulation with taping for stroke rehabilitation. Biomed Res Int. 2021;25: 2021:9912094. https://doi.org/10.1155/2021/9912094. PMID: 34485529; PMCID: PMC8410308.\u003c/li\u003e\n \u003cli\u003eThe Helsinki Declaration of the World Medical Association (WMA). Ethical principles of medical research involving human subjects. Pol Merkur Lekarski 2014;36:298\u0026ndash;301. PMID: 24964504.\u003c/li\u003e\n \u003cli\u003eYen H C, Chen WS, Jeng JS, Luh JJ, Lee YY, Pan GS. Standard early rehabilitation and lower limb transcutaneous nerve or neuromuscular electrical stimulation in acute stroke patients: a randomized controlled pilot study. Clin Rehabil. 2019;33(8):1344-1354. https://doi.org/10.1177/0269215519841420. PMID: 30977392.\u003c/li\u003e\n \u003cli\u003eJung K S, Jung J H, In T S, Cho H Y. Effectiveness of Heel-Raise-Lower Exercise after Transcutaneous Electrical Nerve Stimulation in Patients with Stroke: A Randomized Controlled Study. J Clin Med. 2020;9(11):3532. https://doi.org/10.3390/jcm9113532. PMID: 33142834; PMCID: PMC7692363.\u003c/li\u003e\n \u003cli\u003eCollins DF, Burke D and Gandevia SC. Large involuntary forces consistent with plateau-like behavior of human motoneurons. J Neurosci 2001;21(11): 4059\u0026ndash;4065. https://doi.org/10.1523/JNEUROSCI.21-11-04059.2001. PMID: 11356893; PMCID: PMC6762712.\u003c/li\u003e\n \u003cli\u003eChung BPH, Chiang WKH, Lau H, Lau TFO, Lai CWK, Sit CSY. Pilot study on comparisons between the effectiveness of mobile video-guided and paper-based home exercise programs on improving exercise adherence, self-efficacy for exercise and functional outcomes of patients with stroke with 3-month follow-up: A single-blind randomized controlled trial. Hong Kong Physiother J. 2020;40(1):63-73. https://doi.org/10.1142/S1013702520500079. PMID: 32489241; PMCID: PMC7136530.\u003c/li\u003e\n \u003cli\u003eHui-Chan CWY, Ng SSM, Mak MKY. Effectiveness of a home-based rehabilitation programme on lower limb functions after stroke. Hong Kong Med J. 2009;15:42-46. PMID: 19509438\u003c/li\u003e\n \u003cli\u003eKwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61. https://doi.org/10.1016/j.jphys.2013.12.012. PMID: 24856948.\u003c/li\u003e\n \u003cli\u003eEser F, Yavuzer G, Karakus D, Karaoglan B. The effect of balance training on motor recovery and ambulation after stroke: a randomized controlled trial. Eur J Phys Rehabil Med. 2008;44(1):19-25. PMID: 18385624.\u003c/li\u003e\n \u003cli\u003eBarranco CE, Cuerda RCLC, Porras VA, Rueda\u003csup\u003e\u0026nbsp;\u003c/sup\u003eFM. Postural Assessment Scale for Stroke Patients in Acute, Subacute and Chronic Stage: A Construct Validity Study. Diagnostics (Basel). 2021;21;11(2):365. https://doi.org/10.3390/diagnostics11020365. PMID: 33670068; PMCID: PMC7927023.\u003c/li\u003e\n \u003cli\u003eHuang YC, Wang WT, Liou TH, Liao CD, Lin LF, Huang SW. Postural Assessment Scale for Stroke Patients Scores as a predictor of stroke patient ambulation at discharge from the rehabilitation ward. J Rehabil Med. 2016;48(3):259-264. https://doi.org/10.2340/16501977-2046. PMID: 26667386.\u003c/li\u003e\n \u003cli\u003eVidmar T, Kregar N G, Puh U. Reliability of the modified ashworth scale after stroke for 13 muscle groups. Arch Phys Med Rehabil. 2023;104(10):1606-1611. https://doi.org/10.1016/j.apmr.2023.04.008. PMID: 37121531.\u003c/li\u003e\n \u003cli\u003eMahmood A, Veluswamy SK, Hombali A, Mullick A, Manilandan N, Solomon JM. Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2019;100(4):751-768. https://doi.org/10.1016/j.apmr.2018.10.016. PMID: 30452892.\u003c/li\u003e\n \u003cli\u003eChoi Y, Lee S, Kim M, Chang W. Effects of Neuromuscular Electrical Stimulation with Gastrocnemius Strengthening on Foot Morphology in Stroke Patients: A Randomized Controlled Trial. Healthcare (Basel). 2024; 12(7): 777. https://doi.org/10.3390/healthcare12070777. PMID: 38610199; PMCID: PMC11011460.\u003c/li\u003e\n \u003cli\u003eJung KS\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, In TS, Cho HY. 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. https://doi.org/10.1016/j.gaitpost.2017.03.007. PMID: 28324754.\u003c/li\u003e\n \u003cli\u003eLee YY, Lin KC, Cheng HJ, Wu CY, Hsieh YW, Chen CK. Effects of combining robot-assisted therapy with neuromuscular electrical stimulation on motor impairment, motor and daily function, and quality of life in patients with chronic stroke: a double-blinded randomized controlled trial. J Neuroeng Rehabil. 2015, 12:96. https://doi.org/10.1186/s12984-015-0088-3. PMID: 26520398; PMCID: PMC4628254.\u003c/li\u003e\n \u003cli\u003eGelaw AY, Janakiraman B, Gebremeskel BF, Ravichandran H. Effectiveness of Home-based rehabilitation in improving physical function of persons with Stroke and other physical disability: A systematic review of randomized controlled trials. J Stroke Cerebrovasc Dis. 2020;29(6):104800. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104800. PMID: 32278534.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"TENS, NMES, Stroke, Hemiparesis, Exercise program.","lastPublishedDoi":"10.21203/rs.3.rs-5013498/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5013498/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eSixty 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eConcomitant 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u003c/em\u003e\u003cem\u003eAlthough 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.\u003c/em\u003e\u003c/p\u003e","manuscriptTitle":"The Effects of Concomitant Application of TENS and NMES on Chronic Stroke Patients: A Prospective Randomized Controlled Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-21 06:47:05","doi":"10.21203/rs.3.rs-5013498/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-09T13:04:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-03T09:33:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-03T09:31:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Sports Science, Medicine and Rehabilitation","date":"2024-09-01T15:02:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"86c245d2-ef87-46f4-ab2c-772e436ce5b6","owner":[],"postedDate":"October 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T15:59:11+00:00","versionOfRecord":{"articleIdentity":"rs-5013498","link":"https://doi.org/10.1186/s13102-025-01155-w","journal":{"identity":"bmc-sports-science-medicine-and-rehabilitation","isVorOnly":false,"title":"BMC Sports Science, Medicine and Rehabilitation"},"publishedOn":"2025-04-24 15:56:54","publishedOnDateReadable":"April 24th, 2025"},"versionCreatedAt":"2024-10-21 06:47:05","video":"","vorDoi":"10.1186/s13102-025-01155-w","vorDoiUrl":"https://doi.org/10.1186/s13102-025-01155-w","workflowStages":[]},"version":"v1","identity":"rs-5013498","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5013498","identity":"rs-5013498","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}