Transcutaneous electrical nerve stimulation for balance and gait rehabilitation in stroke survivors: A systematic review and Meta-analysis

Abstract

Objectives

Balance and impairments are common consequences of stroke. For decades, transcutaneous electrical nerve stimulation (TENS) has been used in stroke rehabilitation. This review aims to explore the effects of TENS on balance and gait deficits in stroke survivors and to identify its contraindications.

Methods

“PubMed, Scopus, PEDro, CINAHL, EMBASE, and Web of Science” were searched until February 2025. Randomized trials included stroke survivors, administrated TENS, compared with rest or active interventions, and included scales that assessed gait or balance abilities. The PEDro scale was used to determine the quality of the included studies. Comprehensive Meta-Analysis Version 4 was used for meta-analysis.

Results

Ten studies met the inclusion criteria. In total, 465 patients with stroke (mean age 58.84 years; 65% male) were involved in this review. The included studies&apos; PEDro scale scores ranged from 6 to 9, with a median of 8. The meta-analysis showed a potential effect of TENS on the Timed Up and Go (TUG) test (SMD: 0.458, 95% CI: –0.116 to 1.031, p=0.118, I²=75%), but the results were inconclusive due to lack of statistical significance and high heterogeneity. For gait, the meta-analysis showed a significant positive effect of TENS on the 10-Meter Walk Test (SMD=0.831, 95% CI: 0.448 to 1.214, p<0.001; I²=0%).

Conclusions

TENS may improve gait, but its effect on balance remains inconclusive. It is contraindicated in stroke patients with heart pacemakers, skin issues at the electrode site, severe cognitive impairments, sensory deficits, pregnancy, psychotic disorders, uncontrolled hypertension or diabetes, seizures, and severe heart or lung disease. Further studies are recommended.

Zusammenfassung

Hintergrund und Ziel

Infolge eines Schlaganfalls kommt es häufig zu Beeinträchtigungen des Gleichgewichts und der Gehfähigkeit. Seit Jahrzehnten wird die transkutane elektrische Nervenstimulation (TENS) in der Schlaganfallrehabilitation eingesetzt. Ziel der vorliegenden Übersichtsarbeit ist es, die Wirkungen von TENS auf Gleichgewichts- und Gangstörungen bei Schlaganfallüberlebenden zu untersuchen und Kontraindikationen für die Anwendung von TENS aufzuzeigen.

Methode

Es erfolgte eine Literaturrecherche in den Datenbanken PubMed, Scopus, PEDro, CINAHL, EMBASE und Web of Science bis Februar 2025. Eingeschlossen wurden randomisierte Studien mit Schlaganfallüberlebenden, die TENS erhielten, im Vergleich zu Ruhe oder aktiven Interventionen, sowie Studien, die Gangbild oder Gleichgewichtsfähigkeit mit entsprechenden Skalen erfassten. Die Qualität der Studien wurde anhand der PEDro-Skala beurteilt. Für die Metaanalyse wurde die Software Comprehensive Meta-Analysis (CMA Version 4) verwendet.

Ergebnisse

Zehn Studien erfüllten die Einschlusskriterien. Insgesamt gingen 465 Schlaganfallpatientinnen und -patienten (Durchschnittsalter 58,84 Jahre; 65% Männer) in der Übersichtsarbeit ein. Die PEDro-Skalenwerte der eingeschlossenen Studien lagen zwischen 6 und 9, der Median betrug 8. Die Metaanalyse zeigte einen potenziellen Effekt von TENS auf den Timed Up and Go (TUG)-Test (SMD: 0,458, 95-%-KI: -0,116 bis 1.031, p=0,118, I²=75%), jedoch waren die Ergebnisse aufgrund fehlender statistischer Signifikanz und hoher Heterogenität nicht eindeutig. Hinsichtlich der Gangstörung zeigte sich in der Metaanalyse ein signifikant positiver Effekt von TENS auf die Ergebnisse des 10-Meter-Gehtests (SMD=0,831, 95-%-KI: 0,448 bis 1,214, p<0,001; I²=0%).

Schlussfolgerung

TENS kann möglicherweise die Gehfähigkeit verbessern, doch bleibt dessen Wirkung auf das Gleichgewicht weiterhin unklar. Die Anwendung von TENS ist kontraindiziert bei Schlaganfallpatientinnen und –patienten mit Herzschrittmachern, Hautveränderungen an der Elektrodenstelle, schweren kognitiven Beeinträchtigungen, sensorischen Defiziten, Schwangerschaft, psychotischen Erkrankungen, unkontrolliertem Bluthochdruck oder Diabetes, Krampfanfällen sowie schweren Herz- oder Lungenerkrankungen. Weitere Studien sind erforderlich.

Keywords

Transcutaneous Electrical Nerve Stimulation - Stroke - Gait - Balance - Rehabilitation

Schlüsselwörter

Transkutane elektrische Nervenstimulation - Schlaganfall - Gang - Gleichgewicht - Rehabilitation

Publication History

Received: 26 April 2025

Accepted after revision: 18 July 2025

Article published online:
11 August 2025

• References

• 1 Feigin VL, Brainin M, Norrving B. et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. International Journal of Stroke 2022; 17: 18-29
• 2 Virani SS, Alonso A, Benjamin EJ. et al. Heart disease and stroke statistics—2020 Update: A report from the American Heart Association. Circulation 2020; 141: 1-13
• 3 Duncan PW, Zorowitz R, Bates B. et al. Management of Adult Stroke Rehabilitation care. Stroke 2005; 36: 56-67
• 4 Gittins M, Lugo-Palacios D, Vail A. et al. Stroke impairment categories: A new way to classify the effects of stroke based on stroke-related impairments. Clinical Rehabilitation 2020; 35: 446-458
• 5 Tyson SF, Hanley M, Chillala J. et al. Balance disability after stroke. Physical Therapy 2006; 86: 30-38
• 6 Minet LR, Peterson E, Von Koch L. et al. Occurrence and predictors of falls in people with stroke. Stroke 2015; 46: 2688-2690
• 7 Inness EL, Mansfield A, Lakhani B. et al. Impaired reactive stepping among patients ready for discharge from inpatient stroke rehabilitation. Physical Therapy 2014; 94: 1755-1764
• 8 Walker C, Brouwer BJ, Culham EG. Use of visual feedback in retraining balance following acute stroke. Physical Therapy 2000; 80: 886-895
• 9 Newman AB, Simonsick EM, Naydeck BL. et al. Association of Long-Distance Corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA 2006; 295: 2018
• 10 Lamb SE, Ferrucci L, Volapto S. et al. Risk factors for falling in home-dwelling older women with stroke: The women’s health and aging study. Commentary. Stroke. Published online January 1, 2003 https://pubmed.ncbi.nlm.nih.gov/12574566
• 11 Alashram AR, Padua E, Annino G. Effects of Whole-Body vibration on motor impairments in patients with neurological disorders. American Journal of Physical Medicine & Rehabilitation 2019; 98: 1084-1098
• 12 Alashram AR, Padua E, Annino G. Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials. Journal of Clinical Neuroscience 2022; 105: 115-121
• 13 Park YH, Lee DH, Lee JH. A Comprehensive review: Robot-Assisted Treatments for GAIT Rehabilitation in Stroke patients. Medicina 2024; 60: 620
• 14 Elhamrawy MY, Bahnasy WS, Elkady SM. et al. Effect of functional electrical stimulation of interscapular muscles on trunk performance and balance in post-stroke elderly patients. The Egyptian Journal of Neurology Psychiatry and Neurosurgery 2024; 60: 1-12
• 15 Alashram AR, Annino G, Raju M. et al. Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review. Neurorehabilitation 2020; 46: 455-466
• 16 Hatem SM, Saussez G, Della Faille M. et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in Human Neuroscience 2016; 10: 28-39
• 17 Khan A, Podlasek A, Somaa F. Virtual reality in post-stroke neurorehabilitation – a systematic review and meta-analysis. Topics in Stroke Rehabilitation 2021; 30: 53-72
• 18 Zeng D, Zhao K, Lei W. et al. Effects of whole-body vibration training on physical function, activities of daily living, and quality of life in patients with stroke: a systematic review and meta-analysis. Frontiers in Physiology 2024; 15: 1-17
• 19 Laufer Y, Elboim-Gabyzon M. Does sensory transcutaneous electrical stimulation enhance motor recovery following a stroke? A systematic review. Neurorehabilitation and Neural Repair 2011; 25: 799-809
• 20 Levin MF, Hui-Chan CW. Conventional and acupuncture-like transcutaneous electrical nerve stimulation excite similar afferent fibers. PubMed 1993; 74: 54-60 https://pubmed.ncbi.nlm.nih.gov/8420521
• 21 Johnson MI, Jones G, Paley CA. et al. The clinical efficacy of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain: a protocol for a meta-analysis of randomised controlled trials (RCTs. BMJ Open 2019; 9: e029999
• 22 Vance CGT, Dailey DL, Chimenti RL. et al. Using TENS for pain control: Update on the state of the evidence. Medicina 2022; 58: 1332
• 23 Byl NN, Pitsch EA, Abrams GM. Functional outcomes can vary by dose: Learning-Based sensorimotor training for patients stable poststroke. Neurorehabilitation and Neural Repair 2008; 22: 494-504
• 24 Mahmood A, Veluswamy SK, Hombali A. et al. Effect of transcutaneous electrical nerve stimulation on spasticity in adults with Stroke: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation 2018; 100: 751-768
• 25 Marcolino MAZ, Hauck M, Stein C. et al. Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials. Disability and Rehabilitation 2018; 42: 623-635
• 26 Lin S, Sun Q, Wang H. et al. Influence of transcutaneous electrical nerve stimulation on spasticity, balance, and walking speed in stroke patients: A systematic review and meta-analysis. Journal of Rehabilitation Medicine 2017; 50: 3-7
• 27 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. PLoS Medicine 2021; 18: e1003583
• 28 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies that Evaluate Health Care Interventions: Explanation and Elaboration. PLoS Medicine 2009; 6: e1000100
• 29 Macedo LG, Elkins MR, Maher CG. et al. There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. Journal of Clinical Epidemiology 2010; 63: 920-925
• 30 Foley NC, Teasell RW, Bhogal SK. et al. Stroke Rehabilitation Evidence-Based Review: Methodology. Topics in Stroke Rehabilitation 2003; 10: 1-7
• 31 Cho HY, In TS, Cho KH. et al. A Single Trial of Transcutaneous Electrical Nerve Stimulation (TENS) Improves Spasticity and Balance in Patients with Chronic Stroke. The Tohoku Journal of Experimental Medicine 2014; 229: 187-193
• 32 In TS, Jung JH, Jung KS. et al. Effectiveness of Transcutaneous Electrical Nerve Stimulation with Taping for Stroke Rehabilitation. BioMed Research International 2021; 2021: 1-7
• 33 Chan BKS, Ng SSM, Ng GYF. A Home-Based program of transcutaneous electrical nerve stimulation and Task-Related trunk training improves trunk control in patients with stroke. Neurorehabilitation and Neural Repair 2014; 29: 70-79
• 34 Jung KS, Jung JH, In TS. et al. Effectiveness of Heel-Raise-Lower Exercise after Transcutaneous Electrical Nerve Stimulation in Patients with Stroke: A Randomized Controlled Study. Journal of Clinical Medicine 2020; 9: 3532
• 35 Laddha D, Ganesh GS, Pattnaik M. et al. Effect of transcutaneous electrical nerve stimulation on plantar flexor muscle spasticity and walking speed in stroke patients. Physiotherapy Research International 2015; 21: 247-256
• 36 Park J, Seo D, Choi W. et al The Effects of Exercise with TENS on Spasticity, Balance, and Gait in Patients with Chronic Stroke: A Randomized Controlled Trial. Medical Science Monitor 2014; 20 1890 1896
• 37 Ng SS, Hui-Chan CW. Does the use of TENS increase the effectiveness of exercise for improving walking after stroke? A randomized controlled clinical trial. Clinical Rehabilitation 2009; 23: 1093-1103
• 38 Tyson SF, Sadeghi-Demneh E, Nester CJ. The effects of transcutaneous electrical nerve stimulation on strength, proprioception, balance and mobility in people with stroke: a randomized controlled cross-over trial. Clinical Rehabilitation 2013; 27: 785-791
• 39 Yen HC, Chen WS, Jeng JS. et al. Standard early rehabilitation and lower limb transcutaneous nerve or neuromuscular electrical stimulation in acute stroke patients: a randomized controlled pilot study. Clinical Rehabilitation 2019; 33: 1344-1354
• 40 Yan T, Hui-Chan C. Transcutaneous electrical stimulation on acupuncture points improves muscle function in subjects after acute stroke: A randomized controlled trial. Journal of Rehabilitation Medicine 2009; 41: 312-316
• 41 Chipchase LS, Schabrun SM, Hodges PW. Peripheral electrical stimulation to induce cortical plasticity: a systematic review of stimulus parameters. Clin Neurophysiol 2011; 122: 456-463
• 42 Kaelin-Lang A, Luft AR, Sawaki L. et al. Modulation of human corticomotor excitability by somatosensory input. J Physiol 2002; 540: 623-633
• 43 Murase N, Duque J, Mazzocchio R. et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol 2004; 55: 400-409
• 44 Bütefisch C, Hummelsheim H, Denzler P. et al. Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand. J Neurol Sci 1995; 130: 59-68
• 45 Knutson JS, Fu MJ, Sheffler LR. et al. Neuromuscular Electrical Stimulation for Motor Restoration in Hemiplegia. Phys Med Rehabil Clin N Am 2015; 26: 729-745
• 46 Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965; 150: 971-979 http://ci.nii.ac.jp/ncid/BA72811931
• 47 Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: Basic science mechanisms and clinical effectiveness. Journal of Pain 2003; 4: 109-121
• 48 AlAbdulwahab SS, Al-Gabbani M. Transcutaneous electrical nerve stimulation of hip adductors improves gait parameters of children with spastic diplegic cerebral palsy. Neurorehabilitation 2010; 26: 115-122
• 49 Kirmaci ZİK, Adigüzel H, Göğremiş M. et al. The effect of Transcutaneous Electrical Nerve Stimulation (TENS) and Interferential Currents (IFC) on pain, functional capacity, and quality of life in patients with multiple sclerosis: A randomized controlled, single-blinded study. Multiple Sclerosis and Related Disorders 2023; 71: 104541
• 50 Alenazy MS, Al-Jaafari R, Daneshgar S. et al. Influence of transcutaneous electrical nerve stimulation on the distance walked by older adults during the 6-min test of walking endurance. Journal of Electromyography and Kinesiology 2023; 73: 102827
• 51 Moseley AM, Herbert RD, Sherrington C. et al. Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro). Australian Journal of Physiotherapy 2002; 48: 43-49
• 52 Dubin S. How many subjects? Statistical power analysis in research. Behavior Research Methods Instruments &Amp Computers 1990; 22: 486
• 53 De Sèze M, Gille O. Functional Anatomy of the erector spinae: review. In. Springer eBooks; 2019: 321-327
• 54 Hsu SL, Oda H, Shirahata S. et al. Effects of core strength training on core stability. Journal of Physical Therapy Science 2018; 30: 1014-1018
• 55 Sinsurin K, Valldecabres R, Richards J. An exploration of the differences in hip strength, gluteus medius activity, and trunk, pelvis, and lower-limb biomechanics during different functional tasks. International Biomechanics 2020; 7: 35-43
• 56 Olsen B, Freijomil N, Csonka J. et al. The relationship between hip strength and postural stability in collegiate athletes who participate in lower extremity dominant sports. International Journal of Sports Physical Therapy 2021; 16
• 57 Joudeh AA, Alghadir AH, Zafar H. et al. Effect of quadriceps and calf muscles fatigue on standing balance in healthy young adult males. PubMed 2018; 18: 248-254 https://pubmed.ncbi.nlm.nih.gov/29855447
• 58 Wei Z, Zeng Z, Liu M. et al. Effect of intrinsic foot muscles training on foot function and dynamic postural balance: A systematic review and meta-analysis. PLoS ONE 2022; 17: e0266525
• 59 Button KS, Ioannidis JPA, Mokrysz C. et al. Power failure: why small sample size undermines the reliability of neuroscience. Nature Reviews Neuroscience 2013; 14: 365-376
• 60 Aout T, Begon M, Jegou B. et al. Effects of functional electrical stimulation on GAIT characteristics in healthy individuals: a systematic review. Sensors 2023; 23: 8684
• 61 Tahmasbi F, Ghaderpanah R, Sadrian S. et al. Effects of Transcutaneous Electrical Nerve Stimulation (TENS) on Chronic Pain in Older Adults: a Systematic Review and Meta-Analysis. Current Physical Medicine and Rehabilitation Reports 2023; 11: 242-253
• 62 Kuhn A, Keller T, Lawrence M. et al. The influence of electrode size on selectivity and comfort in transcutaneous electrical stimulation of the forearm. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2010; 18: 255-262
• 63 Gibson W, Wand BM, Meads C. et al Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Cochrane Library Published online April 3, 2019
• 64 Otero-Ortega L, Gutiérrez-Fernández M, Díez-Tejedor E. Recovery after Stroke: New insight to promote brain Plasticity. Frontiers in Neurology 2021; 12
• 65 Coleman ER, Moudgal R, Lang K. et al. Early Rehabilitation After Stroke: a Narrative Review. Current Atherosclerosis Reports 2017; 19
• 66 Su F, Xu W. Enhancing brain plasticity to promote stroke recovery. Frontiers in Neurology 2020; 11: 34-42
• 67 Flodin J, Juthberg R, Ackermann PW. Effects of electrode size and placement on comfort and efficiency during low-intensity neuromuscular electrical stimulation of quadriceps, hamstrings and gluteal muscles. BMC Sports Science Medicine and Rehabilitation 2022; 14: 234-245
• 68 Johnson MI. Transcutaneous electrical nerve stimulation (TENS). Encyclopedia of Life Sciences October 2012
• 69 Teoli D, Dua A, An J. Transcutaneous Electrical Nerve Stimulation. [Updated 2024 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK537188/
• 70 Martimbianco ALC, Porfírio GJ, Pacheco RL. et al. Transcutaneous electrical nerve stimulation (TENS) for chronic neck pain. Cochrane Library 2019; 2019
• 71 Johnson MI, Paley CA, Jones G. et al. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study. BMJ Open 2022; 12: e051073
• 72 Guimarães IB, Lana MRV, De Aquino MRC. et al. Methodological Properties of Transcutaneous Electrical Nerve Stimulation (TENS) Equipment Used for Analgesia in Humans: a Systematic Review. SN Comprehensive Clinical Medicine 2021; 3: 1363-1372
• 73 Alashram AR. Task-oriented training for gait rehabilitation in people with multiple sclerosis: A systematic review. Journal of Bodywork and Movement Therapies 2024; 39: 87-96
• 74 Alashram AR. Effects of robotic therapy associated with noninvasive brain stimulation on motor function in individuals with incomplete spinal cord injury: A systematic review of randomized controlled trials. Journal of Spinal Cord Medicine Published online January 24 2024; 1-16
• 75 Alashram AR. Effectiveness of combined robotics and virtual reality on lower limb functional ability in stroke survivors: A systematic review of randomized controlled trials. Neurological Sciences Published online June 3 2024; 4721-4739
• 76 Berg KO, Wood-Dauphinee SL, Williams JI. et al. Measuring balance in the elderly: validation of an instrument. Can J Public Health 1992; 83: S7-S11 https://pubmed.ncbi.nlm.nih.gov/1468055
• 77 Herman T, Inbar-Borovsky N, Brozgol M. et al. The Dynamic Gait Index in healthy older adults: The role of stair climbing, fear of falling and gender. Gait & Posture 2008; 29: 237-241
• 78 Choi SU, Lee HS, Shin JH. et al. Stroke Impact Scale 3.0: Reliability and Validity Evaluation of the Korean version. Annals of Rehabilitation Medicine 2017; 41: 387
• 79 Duncan PW, Sullivan KJ, Behrman AL. et al. Body-Weight–Supported Treadmill Rehabilitation after Stroke. New England Journal of Medicine 2011; 364: 2026-2036
• 80 Wrisley DM, Kumar NA. Functional GAIT Assessment: Concurrent, Discriminative, and Predictive validity in Community-Dwelling Older Adults. Physical Therapy 2010; 90: 761-773
• 81 Melzack R, Wall PD. The Challenge of Pain. 1996 http://ci.nii.ac.jp/ncid/BA72811931