Non-Invasive Electrotherapy in the Rehabilitation of Motor Sequelae and Spasticity Following Stroke: A Systematic Review

Abstract

Background/Objectives: Stroke is a sudden neurological event caused by disrupted cerebral blood flow and represents a leading cause of acquired disability worldwide. Motor impairments and spasticity are among the most prevalent sequelae, significantly limiting functional independence and quality of life. Non-invasive electrotherapy has emerged as a complementary strategy in neurorehabilitation aimed at enhancing neuroplasticity and improving motor recovery. To systematically review current evidence regarding the effectiveness of non-invasive electrotherapy modalities in the rehabilitation of motor sequelae and spasticity following stroke, and to examine their theoretical and clinical rationale. Methods: A systematic literature review was conducted in accordance with PRISMA 2020 guidelines. The protocol was prospectively registered in the Open Science Framework (OSF). A comprehensive search was performed in Pubmed, Web of Science (WoS), and Scopus for studies published up to 14 November 2023, using the terms “Electric Stimulation Therapy” and “Stroke”. The methodological quality was assessed using the PEDro scale. The levels of evidence were classified according to the Oxford Centre for Evidence-Based Medicine criteria, and the risk of bias was evaluated using the Cochrane Risk of Bias tool (RoB 2). Results: Sixteen studies were included in the review. The analyzed interventions comprised neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), functional electrical stimulation (FES), neuromuscular electrical stimulation combined with transcranial magnetic stimulation (NMES + rTMS), transcranial direct current stimulation (tDCS), and afferent electrical stimulation (AES). Overall, the methodological quality of the included studies ranged from moderate to high, with PEDro scores between 6 and 9 out of 10. According to the Oxford Centre for Evidence-Based Medicine classification, most studies corresponded to level 1b evidence, while a smaller proportion were classified as level 2b. A risk of bias assessment using the Cochrane RoB 2 tool showed that the majority of the included studies presented a low risk of bias across most domains, although some concerns were identified in the domains of randomization and measurement in a limited number of trials. Across modalities, consistency within group improvement in motor function and spasticity was reported. However, between group comparisons with conventional rehabilitation were often inconsistent and did not consistently demonstrate superiority. The variability in stimulation parameters, intervention duration, and outcome measures further limited direct comparisons across studies. Conclusions: Non-invasive electrotherapy appears to be a safe and promising adjunct to conventional stroke rehabilitation. Nevertheless, further high-quality studies are required to clarify the underlying neurophysiological mechanisms and to establish standardized treatment protocols.