The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Clinical Practice Guidelines for Transcutaneous Electrical Nerve Stimulation (TENS)
Low-intensity TENS applied to lower extremity versus placebo, level I (randomized controlled trial [RCT]): Grade A for decrease in spasticity for lower extremity at end of treatment, 2 and 3 weeks (clinically important benefit demonstrated); grade C+ for dorsiflexor strength at end of treatment, 3 weeks (clinically important benefit demonstrated, without statistical significance). Patients with chronic stroke.
Low-intensity TENS applied to the elbow and ankle versus placebo, level I (RCT): Grade A for functional status at end of treatment, 8 weeks (clinically important benefit demonstrated). Patients with post-acute stroke.
Low-intensity TENS applied to the shoulder versus placebo, level I (RCT): Grade C for passive shoulder range of motion (ROM) at end of treatment, 4 weeks, and at follow-up, 4 weeks (no benefit demonstrated). Patients with post-acute stroke.
Low-intensity TENS applied to the upper extremity versus control, level I (RCT): Grade C for motor function (Fugl-Meyer) and functional status at end of treatment, 3 months, and follow-up, 3 years, as well as motor function (change in Fugl-Meyer) and decrease in spasticity (elbow flexors) at end of treatment, 3 months (no benefit was demonstrated); grade D+ for decrease in spasticity (wrist flexors) at follow-up, 3 years (clinically important benefit favoring control, demonstrated without statistical significance); grade D for decrease in spasticity (wrist flexors) at end of treatment, 3 months. Patients with chronic stroke.
High-intensity TENS applied to the shoulder versus placebo, level 1 (RCT): Grade A for passive shoulder ROM at end of treatment, 4 weeks, and follow-up, 4 weeks (clinically important benefit demonstrated). Patients with post-acute stroke.
High-intensity TENS versus low-intensity TENS applied to the shoulder, level I (RCT): Grade A for passive shoulder ROM (extension, abduction, external rotation) at end of treatment, 4 weeks, and follow-up, 4 weeks, and passive shoulder ROM (flexion) at follow up, 4 weeks (clinically important benefit demonstrated); grade C for passive shoulder ROM (flexion) at end of treatment, 4 weeks (no benefit demonstrated). Patients with post-acute stroke.
Low-intensity TENS applied to the hand versus placebo, level II (controlled clinical trial [CCT]): Grade B for sensation at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C for motor function and gait speed at end of treatment, 3 weeks (no benefit demonstrated). Patients with chronic stroke.
Low-intensity TENS applied to the foot versus placebo, level II (controlled clinical trial): Grade B for sensation at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C for motor function and gait speed at end of treatment, 3 weeks (no benefit demonstrated). Patients with chronic stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100