***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This prospect i ve study investigates the frequency of both medical and non-medical complications reported by the population based cohort of SCI survivors reported to the Colorado Spinal Cord Injury Early Notification System ( ENS ) . Persons reported to the ENS between January 1 1986 and December 31 1993 , representing the broad spectrum of all severities of spinal cord injury and potential complications , were solicited to participate in comprehensive follow-up interviews at their first , third and fifth year post injury . Hospitalizations of a week or longer were experienced by more than 10 % of the participants at each of the three interview years . Similarly , the medical complications of spasticity or pain were reported by more than 25 % of the participants , and pressure sores were reported by more than 10 % at all three time periods . The chief non-medical complications ( conditions ) were financial concerns and transportation problems . Although these reported medical and non-medical complications present significant obstacles to be overcome , less than three percent of those surveyed at any of the time periods reported experiencing depression ; and only 14 % rated their quality of life as being poor Background and Purpose — Previous studies have shown that repeated sensory inputs could enhance brain plasticity and cortical motor output . The purpose of this study was to investigate whether combining electrically induced sensory inputs through transcutaneous electrical nerve stimulation ( TENS ) with task-related training ( TRT ) in a home-based program would augment voluntary motor output in chronic stroke survivors better than either treatment alone or no treatment . Methods — Eighty-eight patients with stroke were assigned r and omly to receive a home-based program of ( 1 ) TENS , ( 2 ) TENS+TRT , ( 3 ) placebo TENS+TRT , or ( 4 ) no treatment ( control ) 5 days a week for 4 weeks . Outcome measurements included Composite Spasticity Scale , peak torques generated during maximum isometric voluntary contraction of ankle dorsiflexors and plantarflexors , and gait velocity recorded at baseline , after 2 and 4 weeks of treatment , and 4 weeks after treatment ended . Results — When compared with TENS , the combined TENS+TRT group showed significantly greater improvement in ankle dorsiflexion torque at follow-up and in ankle plantarflexion torque at week 2 and follow-up ( P<0.01 ) . When compared with placebo+TRT , the TENS+TRT group produced earlier and greater reduction of plantarflexor spasticity and improvement in ankle dorsiflexion torque at week 2 ( P<0.01 ) . When compared with all 3 groups , the TENS+TRT group showed significantly greater improvement in gait velocity ( P<0.01 ) . Conclusions — In patients with chronic stroke , 20 sessions of a combined TENS+TRT home-based program decreased plantarflexor spasticity , improved dorsiflexor and plantarflexor strength , and increased gait velocity significantly more than TENS alone , placebo+TRT , or no treatment . Such improvements can even be maintained 4 weeks after treatment ended Spasticity is mostly due to an excess of impulses to alpha motor neurons partly result ing from a change of interneuron activity . Low threshold afferent has been reported to change the activity in interneuron . The purpose of this study is to investigate the effects of surface spinal paravertebral stimulation on knee extensor spasticity . Ten survivors of stroke , with knee extensor spasticity , received electric stimulation for five 45-minute periods through surface electrodes applied to the skin in the twelfth thoracic and first lumbar areas . The electric stimulations had an amplitude modulated alternating current ( AC ) , with a carrier frequency of 2500 Hz , modulated to " beats " frequency of 20 Hz . Stimulation amplitude was raised to elicit sensory stimulation . The pre- and post-treatment evaluation included the modified Ashworth scale , active torque during controlled knee movements at various velocities , and electromyographic ( EMG ) activity during the torque measurements . Our results indicate that nine of ten subjects demonstrated a decrease in the modified Ashworth scale post-treatment . The EMG activity of the spastic quadriceps during active knee flexion was decreased post-treatment as compared with the value before treatment . The active torque value of knee flexion or extension at 30 degrees , 60 degrees , or 90 degrees/sec of angular velocity did not change significantly post-treatment . A trend of increasing spastic quadriceps EMG activity with respect to the angular velocity during an active knee flexion was established , with Ashworth scale considered . The level of EMG activity is higher when the Ashworth scale is higher . According to our results , the surface paravertebral sensory stimulation was effective in reducing quadriceps muscle spasticity of the subjects . Both the modified Ashworth scale and the EMG activity of spastic quadriceps during eccentric contraction are suggested as sensitive tools for measuring spasticity of persons who survived cerebrovascular accident ( CVA ) Evidence -based practice involves the use of evidence from systematic review s and r and omised controlled trials , but the extent of this evidence in physiotherapy has not previously been surveyed . The aim of this survey is to describe the quantity and quality of r and omised controlled trials and the quantity of systematic review s relevant to physiotherapy . The Physiotherapy Evidence Data base ( PEDro ) was search ed . The quality of trials was assessed with the PEDro scale . The search identified a total of 2,376 r and omised controlled trials and 332 systematic review s. The first trial was published in 1955 and the first review was published in 1982 . Since that time , the number of trials and review s has grown exponentially . The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999 . There is a substantial body of evidence about the effects of physiotherapy . However , there remains scope for improvements in the quality of the conduct and reporting of clinical trials Background Transcutaneous electrical nerve stimulation ( TENS ) is a useful modality for pain control .  TENS has recently been applied to decrease spasticity . The purpose of this study is to determine whether the addition of TENS to an exercise program reduces spasticity and improves balance and gait in chronic stroke patients . Material / Methods This was a single-blinded , multicenter , r and omized controlled trial . Thirty-four ambulatory individuals with chronic stroke participated and were r and omly allocated to the TENS or Placebo group . The TENS group performed therapeutic exercise with TENS while the placebo ( non-stimulation ) TENS group performed therapeutic exercise with placebo TENS . Participants in both groups followed the same 30-min exercise regimen 5 times per week for a period of 6 weeks . Spasticity ( modified Ashworth scale ) , static ( balance system ) , and dynamic balance ( timed up and go test ) , and gait ability ( gait analyzer ) were measured at 1 week before and 1 week after the intervention . Results Significant differences were observed between the 2 groups . Spasticity improved by 0.80 points in the TENS group . Anterior-posterior and medial-lateral sway velocity among static balance parameters and dynamic balance showed significant differences between the TENS and Placebo TENS groups ( p=.000 ) . Gait speed and cadence were enhanced significantly in the TENS group ( p=.000 ) . Step and stride length on the paretic side showed a significant difference in the TENS group ( p=.000 ) , while only velocity showed a significant difference in the Placebo TENS group ( p=.004 ) . Conclusions A combination of therapeutic exercise and TENS may reduce spasticity and improve balance , gait , and functional activity in chronic stroke patients BACKGROUND The disorder of reflex and motor function in patients affected by stroke causes negative impact on the performance of movement patterns and affects the functional activities . OBJECTIVES To investigate the immediate effects of transcutaneous electrical nerve stimulation ( TENS ) and cryotherapy interventions on the spinal reflex excitability and in the voluntary electromyography ( EMG ) activity in people with chronic stroke . METHOD R and omized crossover trial . The maximum H-reflex ( Hmax ) , the H-reflex latency and the maximum motor response ( Mmax ) of the soleus muscle and also the EMG of the tibialis muscle where evaluated before and after the application of TENS , cryotherapy and control conditions . RESULTS The Hmax/Mmax ratio was statistically significant higher ( p=0.0245 ) and the H-reflex latency was statistically significant lower ( p=0.0375 ) in the soleus muscle of the affected limb . The EMG amplitude of the tibialis anterior was reduced in the compromised limb ( p<0.0001 ) . After the use of the TENS , a reduction in the Hmax/Mmax ratio ( p=0.0006 ) was observed leading to lower reflex excitability . However , after the cryotherapy intervention an increase of the Hmax/Mmax ratio was observed , which was accompanied by an increase in the H-reflex latency ( p=0.0001 ) . The EMG amplitude has not changed by any of the interventions . CONCLUSIONS Our findings suggest that TENS may be a choice for immediate reduction of reflex excitability , whereas cryotherapy intervention may increase reflex excitability in hemiparetic subjects . However , none of the changes mediated by either intervention were able to modify the electrical activity in the antagonist muscle of the spastic muscle Spasticity leads to functional and structural changes in nerves and muscles , which alter skeletal muscle function . To evaluate whether short-term electrical nerve stimulation ( NS ) improves the effect of botulinum toxin in spastic skeletal muscle , we studied changes in the amplitude of the compound muscle action potential ( CMAP ) recorded from the extensor digitorum brevis ( EDB ) muscle in response to peroneal nerve stimulation at the ankle after injection of botulinum toxin type A ( BTXA ) alone or combined with short-term NS . In paraparetic patients , both EDB muscles were injected with BTXA ; and NS was applied to one EDB muscle alone . All patients received a 30-minute session of electrical NS once a day for 5 consecutive days after BTXA injection . We used two different stimulation frequencies ( low-frequency , 4 Hz ; and high-frequency , 25 Hz ) . EDB-CMAP amplitudes were evaluated before BTXA injection ( day 0 ) and changes in CMAP amplitude , expressed as a percentage ( CMAP% ) , were measured at various time points over a 30-day period after BTXA injection . We compared changes in the CMAP% amplitude on the stimulated and contralateral nonstimulated sides . We also studied the electromyographic activity recorded from EDB muscles over a 30-day period . CMAP% amplitudes measured at all time points after BTXA injections were significantly reduced in both EDB muscles . On days 4 , 10 , and 15 , the CMAP% amplitude reduction was significantly greater for the low-frequency stimulated EDB than for the contralateral nonstimulated EDB . No significant differences in CMAP% were observed for the high-frequency stimulated and nonstimulated EDB . After BTXA injection , spontaneous activity appeared in both EDB muscles ; but it appeared earlier and involved larger areas in the stimulated than in the nonstimulated EDB . In conclusion , short-term NS accelerates the effectiveness of intramuscular BTXA injections on the neuromuscular blockade in patients with spastic paraparesis and could induce a rapid and persistent improvement in spasticity . Its action probably arises mainly from low-frequency NS Training of spinal cord circuits using sensorimotor stimulation has been proposed as a strategy to improve movement after spinal injury . How sensory stimulation may lead to long-lasting changes is not well understood . We studied whether sensory stimulation might induce changes in the strength of a specific spinal interneuronal circuit : spinally mediated reciprocal Ia inhibition . In healthy humans , the strength of reciprocal inhibition between ankle flexor and extensor muscles was assessed before and after 30 min of peroneal nerve stimulation at motor threshold intensity . Three stimulation protocol s were assessed : patterned nerve stimulation ( 10 pulses at 100 Hz every 1.5 sec ) , uniform nerve stimulation ( one pulse every 150 msec ) , and combined stimulation of the peroneal nerve and the motor cortex with transcranial magnetic stimulation .  Short-latency reciprocal inhibition from ankle flexor to extensor muscles was measured by conditioning the soleus H-reflex with stimulation of the common peroneal nerve . The strength of the reciprocal inhibition was measured at baseline and for 20 min after each stimulation session . Patterned stimulation , with or without motor cortex stimulation , enhanced reciprocal inhibition for at least 5 min afterward . The uniform pattern of stimulation was ineffective . These results demonstrate the presence of short-term plasticity within spinal inhibitory circuits . We conclude that the pattern of sensory input is a crucial factor for inducing changes in the spinal circuit for reciprocal inhibition in humans . These findings may have implication s for the use of repetitive patterned sensory stimulation in rehabilitative efforts to improve walking ability in patients with spinal injury Our previous studies showed that a single 45 min application of transcutaneous electrical nerve stimulation ( TENS ) prolonged soleus H and stretch reflex latencies in hemiparetic subjects . In addition , 9 daily 30 min TENS applications enhanced vibratory inhibition of the H reflex and tended to decrease hyperactive stretch reflexes . These findings suggested that longer-term TENS may be effective in reducing hemiparetic spasticity . Our present objectives were 2-fold : to determine whether longer-term repetitive TENS stimulation would lead to a reduction in clinical spasticity in hemiparetic subjects , and whether such a reduction could be associated with a decrease in stretch reflex excitability and an improvement in voluntary motor function . We compared 
    Output:
    
There was level 1 and 2 evidence for TENS  improving spasticity-related outcome measures within the International Classification of Functioning , Disability , and Health domains of body structure and function ( e.g. , Modified Ashworth Scale ) as well as activity ( e.g. , gait ) .
Better responses in outcome measures in the International Classification of Functioning , Disability , and Health activity domain were seen when TENS was used in combination with active therapy ( e.g. , exercise and task-related training ) vs. as a single therapeutic modality