Is radial extracorporeal shock wave therapy (rESWT) more effective than transcutaneous electrical nerve stimulation (TENS) in treating the upper limb spasticity of patients with chronic post-stroke hemiplegia?

The study will be conducted at teaching hospital, Peradeniya and at the Department of Physiotherapy, Faculty of Allied Health Sciences, University of Peradeniya..

The control group will receive transcutaneous electrical nerve stimulation (TENS), frequency of 100 Hz over Teres major, Brachialis, Flexor carpi ulnaris and Flexor digitorum profundus muscles, fifteen minutes for each muscle followed by task oriented exercises for upper limb for 30 minutes. The experimental group will receive radial extracorporeal shock wave therapy (rESWT), 1500 shots per muscle, frequency of 5Hz, energy of 0.030 mJ/mm, over Teres major, Brachialis, Flexor carpi ulnaris and Flexor digitorum profundus muscles followed by task oriented exercises for upper limb for 30 minutes. All the patients will receive transcutaneous electrical nerve stimulation or radial extracorporeal shock wave therapy once a week for four weeks continuously according to the group to which he or she was assigned. All the patients will receive the task oriented exercises three times per week for four weeks. All the subjects will be assessed for their voluntary movement grading for the upper limb, spasticity grading for upper limb and their hand function grading immediately after the TENS or rESWT treatment has been given, at the end of the four weeks of treatment and after eight, twelve, sixteen and twenty weeks. After four weeks of the treatment session patients will be asked to follow the task oriented exercises for upper limb at home.

1. Male and female patients aged between 40 to 70 years diagnosed with stroke resulting in hemiplegia more than six months ago 2.Stable spasticity (no variability within two months before recruitment) in upper limb
2. Patients with more than grade three of Modified Ashwath Scale
   1. Patients with Voluntary Control Grading from two to four for affected UL
3. Able to maintain standing position for five minutes without manual assistance
4. Able and willing to participate in four weeks study and to sign consent form

1.Patients with reflex sympathetic dystrophy/ severe shoulder subluxation/ shoulder dislocation/ contracture in the affected UL/ fixed deformity of hand/ shoulder hand syndrome 2.Any neurological disorder or pain that might limits arm movement 3. Patients who have received botox injection or acupuncture within past 6 months to the affected UL 4. Complete sensory loss of upper limb 5. Presence of high risk cardiovascular disorders such as myocardial infarction, heart failure 6. Severe hypertension defined as SBP? 180 and or DBP ? 110 7. Presence of convulsions 8. Patients with visual impairment 9. Patients with behavioral problems 10. Already enrolled in some form of physical therapy