ORIGINAL RESEARCH ARTICLE
published: 20 June 2011
doi: 10.3389/fneur.2011.00039

The effect of electrical passive cycling on spasticity in war
veterans with spinal cord injury
Seyed Mansoor Rayegani 1 *, Hadi Shojaee 2 , Leyla Sedighipour 1 , Mohammad Reza Soroush 2 ,Mohammad Baghbani 2 and Omm’ol Banin Amirani 2
1
2

Department of Physical Medicine and Rehabilitation, Shohada Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Jaanbazan Medical Engineering Research Center, Tehran, Iran

Edited by:
Saumyajit Basu, Park Clinic, India
Reviewed by:
Harvinder Singh Chhabra, Indian
Spinal Injuries Centre, India
Shankar Acharya, Sir Gangaram
Hospital, India*Correspondence:
Seyed Mansoor Rayegani, Professorof Physical Medicine andRehabilitation, Department of Physical
Medicine and Rehabilitation, Shohada
Hospital, Shahid Beheshti Universityof Medical Sciences, Tehran, Iran.
e-mail: rayegani@gmail.com

Introduction: Muscle atrophy, spasticity, and deformity are among long term complication of spinal cord injury (SCI) veterans. There are numerous studies evaluating effect offunctional electrical stimulation on muscle properties of SCI people, but less research has
focused on the beneﬁts of passive cycling in the management of spasticity and improving
ROM of lower limbs in individuals with SCI. Aims:To evaluate the effect of electrical passive
cycling on passive range of movement spasticity and electrodiagnostic parameters in SCI
veterans. Methods: Sixty-four SCI veterans referred to two clinical and research center inTehran were recruited in this prospective clinical trial. The subjects were divided into twogroups according to electrical passive cycling usage: (1) patients who did not use pedal
exercise (control group), (2) patients used Electrical passive cycling up to optimal level (intervention group). Main outcome measures included hip, knee, and ankle range of motion,
spasticity scale, and electrodiagnostic parameters including F-Wave Consistency, F-Wave
Amplitude, H/M Ratio, F/M Ratio, H-Reﬂex Onset Latency, and H-Reﬂex Amplitude. Data
were recorded at the time of receiving and 1 year after pedal exercise usage. Results: Sixtyfour SCI patients including 95.3% male, 4.7% female with mean age 43 years old were
included in this study. All patients except one suffered from complete SCI. The involved
spinal levels were cervical (17.2%), upper thoracic (34.4%), lower thoracic (45.3%), andlumbar (3.1%). Spasticity scale decreased signiﬁcantly after passive cycling in group 2.
Also hip, knee, and ankle ROM in group 2 were signiﬁcantly improved after pedal exercise.
There was a signiﬁcant difference in H max/M max (RT&LT) and F/M ratio after versus
before electric passive cycling system in group 2. Conclusion:These ﬁndings suggest that
passive rhythmic leg exercise can lead to decrease in spasticity, increase in passive ROMof lower limbs and improvement in electrodiagnostic parameters of spasticity in patientswith SCI.
Keywords: spinal cord injury, spasticity, electrical passive cycling

INTRODUCTION
Spinal cord injury (SCI) is one of the critical and devastating
injuries. As time grows, SCI causes widespread disability and dysfunction (Braddom, 2007). During the early part of the twentiethcentury, there was little progress made in the management of
SCI, and most persons with SCI died within weeks or months.
Nowadays due to medical and Rehabilitation development, life
expectancy has grown as well (McArdle et al., 1994; Braddom,
2007; Frontera, 2008). As a consequence of relative sedentary orcomplete inactivity life style, these patients encounter muscle atrophy, joints stiffness, spasticity and deformity, cardiopulmonary
sequelae, and other systemic complications. Any of the above
mentioned phenomenon intensiﬁes their disability (Daivis, 1993;
Frontera, 2008), and lead to decreased quality of life and signiﬁcant medical costs. Below the level of a SCI, the paralyzed muscles
become atrophied It is considered that physical exercises on a continuous and precise basis maintains muscle tone both in trunks andthe limbs, leading to prevention of joint contracture, maintenanceof ﬂexibility in joints and muscles and enhancement of the internalorgans functions (Braddom, 2007; Devillard et al., 2007).
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Physiotherapy, mechanical, and electrical equipments are usual
methods prescribed for performing physical exercise in spinal cord
injured patients, but they are time consuming and costly (Sköld
et al., 2002; Duffell et al., 2008; Szecsi and Schiller, 2009). In recent
years, new methods are introduced to help patients conduct physical exercises independently at home and this has been an evolution
and a great progress. Electrical passive pedaling systems (EPPS)
are among these innovated rehabilitation technologies by which
the handicapped patients practice physical exercises independently(Therese et al., 2008). Passive rhythmic exercises entails several
physical effects (Mutton et al., 1997). The main aim of passive
movements of the legs is to preserve full range of motion over thejoints that are immobilized and claim to have an effect on spasticity(Kakebeeke et al., 2005).
Even though there are numerous studies evaluating effect offunctional electrical stimulation (FES) on muscle properties of
SCI people, less research has focused on the beneﬁts of passive
cycling in the management of spasm and improving ROM of lower
limbs in individuals with SCI (Sköld et al., 2002; Duffell et al.,2008; Therese et al., 2008). Improvements have been reported inJune 2011 | Volume 2 | Article 39 | 1

Rayegani et al.

spasticity (Kakebeeke et al., 2005), cardiac output and stroke volume (Therese et al., 2009), and muscle atrophy after a program ofpassive cycling (Therese et al., 2008).
Even though, SCI veterans are not suffering from geriatricsequelae, their physical condition and sedentary life style following the spinal injury makes cardiopulmonary disorders in veterans
expectable. During active physical exercises, e.g., using EPPS, there
will appear tachycardia, hypertension, and headache. Therefore,
the exercise duration should be decreased and then again increased
but gradually or even in some cases, unfortunately, quit the exercise. And this is one of several factors upon which we decided
to conduct a research focusing on the usage method of EPS inveterans.
Furthermore; EPPS or electrical passive cycling has recently
been applied for physical therapy in veterans; and as its effect on
joints spasticity and electrodiagnosis parameters is not yet deﬁned.
Physical effects of EPPS usage in Iranian veterans with SCI had
been studied in this trial and both objective and subjective signs
in relation with EPCS/EPPS were assessed.

MATERIALS AND METHODSPATIENTS

The present trial is a prospective clinical research performed on
64 SCI veterans.
According to the study method, all the SCI Veterans living
in Tehran were invited to receive the Electric Passive Cycling
equipment and to undergo clinical and electrodiagnostic tests by
the assigned PM and R MDs of Shohada Hospital and JMERC(Janbazan Medical Engineering Research Center) which is afﬁliatedto The Health deputy of the Foundation of Martyrs and Veterans
Affair.
The criteria upon which the subjects recruited were as perfollow:a. The participant should be with SCI and provided with theelectric passive cycling system.
b. The Veteran should be willing to participate and cooperate in
the study,
Exclusion criteria:
1. Lower limb fracture.
2. Any other orthopedic disease in lower limbs.
3. Inappropriate collaboration during the course of trial.
Before the initiation of the trial, written consent had been signed
by each of the participants with above criteria.

Passive cycling effect in SCI

using random number table to two groups: intervention (passive
cycling) and control group (physical therapy). Equal allocation
between two treatment arms were considered. Type of design wasparallel group.
Routine physical therapy including stretching, ROM, andstrengthening exercises were considered for control group. Thirtyseven veterans selected in control and intervention group during
study period which was 2 months, eight patients from control were
dropped from the study because they did not participate in physical therapy program regularly. Two patients from intervention
group were dropped from the study due to inaccurate and irregular use if EPPS (Figure 1). Finally 64 patients completed the study
and their data was analyzed.
INTERVENTION GROUP

Intervention group were placed in their own wheelchair in frontof a motorized cycle (THERA-vital, Medica Medizin GmbH,
Hochdorf, Germany). The veteran’s legs were passively moved ina standardized way by that motorized cycle for required period oftime.
The method of exercise with the pedaling system were taught
to the veterans, its probable risks and beneﬁts, and the features ofthis research plan.
Gradual increase in the length of exercise to the target levelof 20 min/set repeating three times a day was a guideline to be
performed for 2 months.
Hence; SCI veterans were divided into two groups regarding
cycling usage:
Group 1 (Control group) The veterans who did not use
EPPS but just receive physical therapy for 2 months. (29 veterans); Group 2 (Intervention group) The veterans who used EPPS
optimally/up to optimal level (35 veterans).
All patients were permitted to continue their previously activities including standing and walking with braces but were notpermitted to participate in non-study-related lower extremity
repetitive motion tasks or electrically stimulated exercise.
All veterans in intervention group signed informed consent
forms, which was approved by the governing institutional review
board.
DATA COLLECTION

Demographic information was obtained by interviewing with thepatients. All data including clinical examination results, goniometric parameters, and electrodiagnostic ﬁndings (before and after
intervention) were recorded in patients’ ﬁles.

STUDY DESIGN

CLINICAL DATAIn this randomized prospective clinical trial, 74 veterans wererecruited during 2 years. After being visited by the PM&R MD
and ﬁlling up the questionnaire of the veterans plan, they were
provided with the required introductory letter to the delivering division temporarily established in the Research Center ofJanbazan (veterans).
At the time, a simple randomization was performed, all patientwith inclusion criteria were allocated by a random numbers and by

Physical examination data, e.g., muscle strength (according to
Kondal Scale; Braddom, 2007), level of SCI, spasticity scale[Ashworth et al. (2004) Modiﬁed, were obtained by Physical Medicine and Rehabilitation (PM&R) MD through examinations andobservations. All examinations and tests had been performed by
two assigned PM&R MD].
In order to measure the passive range of motion in joints,
Goniometer was utilized.

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Rayegani et al.

Passive cycling effect in SCI

FIGURE 1 | Flow chart of the patients.

ELECTRODIAGNOSISElectrodiagnostic tests were conducted via a pair of two-channeled
TOENNIES-PLUS, German made devices in the research and academic center. Electrodiagnosis was performed and reported by a
PM&R MD.

study protocol (passive cycling in group 1 and physical therapy ingroup 3) 1 year after ﬁnishing study protocol.
Finally, the results of clinical evaluations performed 1 year afterﬁnishing the study protocol were reported.
ELECTRODIAGNOSTIC PARAMETERS

OUTCOME MEASUREMENTThe objective signs evaluated in veterans were as per follow: (1)Hip, knee, and ankle passive range of motion, (2) spasticity scale(according to Modiﬁed Ashworth Scale).
All clinical assessments were performed three times during thestudy: (1) at the ﬁrst day of study, (2) 2 months later after ﬁnishingwww.frontiersin.org

We performed the electrodiagnostic tests by a two channel synergy
electrodiagnostic instrument• H-Reﬂex (LT&RT), Amplitude – Change• H (max)/M (max), H (max)/M (max) – change, H-Reﬂex(RT&LT), Onset Latency – Change

June 2011 | Volume 2 | Article 39 | 3

Rayegani et al.

Passive cycling effect in SCI• F – Wave – (RT&LT) – Consistency – Change, F-Wave –(RT&LT), Amplitude – Change.
F/M RATIO (RT&LT) CHANGE

The variables mentioned above had been measured three times
during the trial: (1) at the ﬁrst day of study (the same daythat subjects were recruited), (2) 2 months later after ﬁnishing
study protocol (passive cycling in group 1 and physical therapy ingroup (3) 1 year after ﬁnishing the period of the study, we commenced another series of electrodiagnostic tests in both associatedcenters and in both two groups with different therapy protocol.
Each subject was examined by the exact PM&R MD who had
visited them in the ﬁrst phase last year.
Hence, the electrodiagnostic tests (at the ﬁrst day of the study
and after 1 year) were performed at the ﬁxed time for all subjects.
Finally, the results of electrophysiologic tests performed 1 year
after ﬁnishing the study protocol were reported.

beginning of the study). However, as the results of 1 year follow
up was the same as the results obtained immediately after completing 2 month study protocol, we reported the results of 1 year
follow up.
SPASTICITY SCALE

In Group 1 who did not use the EPPS at all, there was shown nosigniﬁcant change in the mean Ashworth spasticity scale before
and after launching the EPPS. Meanwhile, in Group 2 who had
used the EPPS up to the optimal level, the mean Spasticity Scale
before application of EPPS was more than the mean Spasticity
Scale after EPPS usage (P = 0.003).
PASSIVE ROM

In order to analyze the data resulted from the study, we utilized
Paired t -test, Single way Analysis of Variance, and Kruskal Wallis
test. P < 0.05 was considered as the signiﬁcance level.

In the group who did not use EPPS at all (Group 1) there wasfound no signiﬁcant difference in mean ROM of hip (Add., Abd.,
Flex., Ext., Internal, and External Rotation), knee ﬂexion, ankle
dorsiﬂexion, and plantar ﬂexion.
Finally, in Group 2 who used EPPS on an optimal basis, except
for knee ﬂexion, there was shown signiﬁcant increase for ROM
of hip (Abd, Add., Flex, and Ext), ankle dorsiﬂexion and plantar
ﬂexion (Table 2).

RESULTS

ELECTRODIAGNOSTIC DATA

PRE-INTERVENTION DATA

In both intervention and control group, there was no signiﬁcantdifference in H-Reﬂex amplitude either before or after launching
the EPPS.
There was a signiﬁcant difference in decreasing H max/M max(RT&LT) and F/M ratio after versus before exercising with the electric passive cycling system among the veterans who had exercisedto the target level (Table 3).
Nevertheless, regarding other measured variables, there was noremarkable difference between those two groups.

DATA ANALYSISThe participants included 93.5% male veterans and 4.7% female
ones. The mean age of patients was 43 years old, while most of thecases (21 persons = 32.8%) had become SCI during 1985–1986.
All patients except one suffered from complete SCI. The
involved body area included cervical injury in 11 subjects (17.2%),
upper thoracic injury in 22 (34.4%), and lower thoracic injury
in 29 (45.3%), and lumbar spinal injury in two patients (3.1%;
Table 1).
SCI SEVERITY

One patient was categorized as being in ASIA B (Braddom, 2007).
The rest of patients had complete motor SCI (ASIA A).
The ﬁnal results of spasticity and ROM change, also electrophysiologic tests performed 1 year after ﬁnishing the study
protocol were presented here. We also measured all these parameters immediately after ﬁnishing study protocol (2 months after

DISCUSSION
Mean age for Iranian veterans participated in this study was 40–
45 years old, which is considered young likewise other countries
that SCI primarily affects young men (Braddom, 2007; Frontera,2008).
In our study, the most frequent level of injury was thoracic level.
Hence; almost all of the SCI veterans in our study suffered from

Table 1 | Motor and sensory distribution of the right and left spinal injury in SCI Veterans who were recruited in the study on EPPS application.
Spinal regions

Right

Left

Motor region of

Sensory region ofMotor region of

Sensory region of

the spinal injury

the spinal injury

the spinal injury

the spinal injury

No.

%

No.

%

No.

%

Cervical11

Upper thoracic

22

Lower thoracic

17.2

8

12.5

12

34.4

20

31.3

21

29

45.3

28

43.8

Lumbar2

3.1

2

Unidentiﬁed

0

0

Total

64

100

Frontiers in Neurology | Spinal Cord Medicine

No.

%

18.8

8

12.5

32.8

20

31.3

28

43.8

28

43.8

3.1

2

3.1

1

1.6

0

0

1

1.6

7

10.9

64

100

64

64

100

100

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Passive cycling effect in SCI

Table 2 | The comparison between mean ROM of joints in Lower limbs
before and after receiving the EPPS protocol in veterans used the
EPPS optimally.
Variant
Hip abd. ROM
Hip add. ROM
Hip ﬂex. ROM
Hip ext. ROM
Knee ﬂex ROM
Ankle dorsiﬂex ROM
Ankle plantar ﬂex

Mean value

SD

Before EPPS

18.9655

9.3902After EPPS

23.1034

7.6080

Before EPPS

15.86217.3276After EPPS

18.9655

5.5708Before EPPS

85.3448

22.2779

After EPPS

103.7931

13.9933

Before EPPS

7.41387.8627After EPPS

12.0690

6.1986

Before EPPS

89.3103

28.0218

After EPPS

150.000

204.7646

Before EPPS

3.57145.4189After EPPS

13.57146.2148Before EPPS

9.821410.2227

After EPPS

19.2857

10.8622

P value
0.003
0.005
0.000
0.000
0.111
0.000
0.000

According to the table, apart from knee ﬂexion, mean difference in the rest ROM
was signiﬁcant (P < 0.05).

Table 3 | Comparison between mean value of LT H (max)/M (max) andRT H (max)/M (max), before and after EPPS application in veterans
who conducted the pattern of optimal exercise with EPPS.
Variables

Mean valueSD

P value

RT H (max)/M (max) 1

0.39840.19020.000

RT H (max)/M (max) 2

0.19630.1348LT H (max)/M (max) 1

0.40220.1828LT H (max)/M (max) 2

0.19890.1176

RTF/M ratio 1

0.20630.2631

RTF/M ratio 2

0.09230.1399LTF/M ratio 1

0.2036

0.2697

LTF/M ratio 2

0.07170.1043

0.000
0.027
0.025

1, Before exercise; 2, after exercise.

mostly complete lower limbs disability. According to internationalreferences, cervical spinal cord injuries occur more frequently thanthoracic and lumbar injuries (Frontera, 2008).
The next issue is that, most of the veterans had been injured
when the Iran–Iraq war was on its prime days, but they developed SCI complications gradually during 15–20 years after theirprimary injury at war days.
We assessed mainly objective signs in this study and it is
to be emphasized that considering objective signs is signiﬁcantbecause it crosses out the interference from patients, leading to
the measurement of interventional factors and shows their crucial
effect.
RANGE OF MOVEMENTThe ROM for lower limbs are of high signiﬁcance in SCI veterans
health condition since long term sedentary life leads to comparative stiffness in the joints (McArdle et al., 1994; Braddom, 2007;
Frontera, 2008). Gently loosening and increasing ROM in these

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joints are the ultimate goals of rehabilitation in these veterans andif sustained it will be an immense contribution to them.
In our study, in veterans who used EPPS on an optimal basis,signiﬁcant increase for ROM of hip, ankle dorsiﬂexion, and plantar ﬂexion were noticed, indicating effective role of EPPS on ROM
of these joints.
However, no change in knee ﬂexion ROM was noticed. There
could be an explanation for that ﬁnding. In patients with optimum
knee ﬂexion from the very beginning of the trial, no alteration in
ROM values was noticed and it was due to their original proper
knee ﬂexion. While those without proper knee ﬂexion probably
could not use EPPS properly and obtain appropriate results fromexercising with EPPS.
In similar studies conducted to determine the effects of passive leg cycle exercise in patients with SCI, increased muscle force
and torque output were observed in SCI patients (Hjeltnes et al.,
1997; Scremin et al., 1999). In another study, exercise endurance,
pedal revolutions per minute (rpm) and peak power output were
improved after 8 weeks of training (3 days/week; Priest et al., 1995;
Krause et al., 2008).
Long term FES cycling was shown to enhance ﬁtness, decrease
insulin resistance, and increase mass in persons with SCI (Braddom, 2007), it can improve quadriceps muscle strength (Therese
et al., 2008), and to a lesser extent, cycling power output
signiﬁcantly (Duffell et al., 2008; Therese et al., 2008).
Even though there are numerous studies evaluating effectof FES on muscle properties of SCI people, less research has
focused on the beneﬁts of passive cycling in individuals with SCI(Kakebeeke et al., 2005; Therese et al., 2008).
The mean spasticity scale in veterans who practiced with thepedaling device to the target level or below the target showed signiﬁcant decrease in comparison with the spasticity scale before
providing the electric passive cycling system. This is to show thesigniﬁcant effect of exercise with EPPS in decreasing the spasticity.
Passive rhythmic activities reported to improve Spasticity (Katz,
1991; Nuyens et al., 2002; Sköld et al., 2002). FES propelled cycling
lead to reduced spasticity in SCI subjects who achieved smoothpedaling in different studies (Hoffman, 1986; Katz, 1991; Krause
et al., 2008; Szecsi and Schiller, 2009). In a study by Rösche et al.
(1997) a motorized exercise-cycle was also used to treat spasticity
in subjects who suffered predominantly from multiple sclerosis.
However, in two other experiments, no signiﬁcant reduction in
spasticity with Ashworth scale was noticed after rhythmic passive
movements of the legs in SCI subjects. However, subjectively, thepatients proﬁted from the cycling (Kakebeeke et al., 2005; Therese
et al., 2008).
Regarding Electrodiagnostic ﬁndings, EPPS had no effects on
reduction of H-Reﬂex and F-wave amplitudes in our study. This isagainst Rösche’s ﬁndings through his research. In his study, mean
F-wave amplitude, mean F-wave/M-response ratio, and maximum
F-wave/M-response ratio were signiﬁcantly lower after utilizing a
motorized exercise-cycle than before. Though it is to be emphasized that he had not evaluated the usage of EPPS for a long
period of time (Rösche et al., 1997), while in the current study
the effect of EPPS on F-wave amplitude was evaluated after 1 year
period and no reduction in F-wave amplitude was demonstrated.
However, like Rösche’s study, mean F/M wave and H/M reﬂex wasJune 2011 | Volume 2 | Article 39 | 5

Rayegani et al.

Passive cycling effect in SCI

decreased after cycling. Clinically this electrophysiologic change
can be reﬂected in reducing spasticity related to loss of supraspinal
inhibitory mechanisms noticed in SCI patients. In Rösche’s study,
it was suggested that F-wave amplitudes can be used to showchanges of motor neuron excitability in patients receiving antispastic therapy and document the effect of the therapy withmotorized passive cycling.
Spinal cord injury subjects are prone to cardiovascular disorders leading to increased risk of mortality, due to their physicalinactivity and dependency for mobility (Nuyens et al., 2002; Ballaz
et al., 2007). Passive leg cycle exercise was shown to have positive effects on vascular blood ﬂow velocity (Ballaz et al., 2007),
also oxygen uptake (VO2). Regular lower leg exercise can result insigniﬁcant gains not only in physical, but also psychological wellbeings (Lannem et al., 1990; Hicks et al., 2003; Hjeltnes, 2009).
Nowadays, there are also commercially available powered cycle
trainers that subjects can use at home (Therese et al., 2008).
In conclusion, We found beneﬁcial physical effect of EPPS
in our study represented in electrodiagnostic and other objective measures in SCI veterans. The spasticity level was reduced
and passive ROM were also improved in SCI veterans used EPPS

at optimal level. Furthermore, these positive effects 1 year after
passive cycling was stopped, was similar to the results obtained
immediately after 2 month passive cycling. Our results demonstrated that patients using EPPS gained better results comparedwith manual passive movements. EPPS is a method of achieving
continues and regular passive movement, but stretching parameters like speed or smoothness of passive movement may not
be controlled by manual stretching. We suggest that response toelectrical passive cycling can be monitored via measuring electrophysiological parameters besides clinical spasticity measurement
scales (Ashworth’s scale, etc.). Monitoring motor neuron excitability via measuring electrophysiologic parameters was also indicatedin previous studies (Fox and Hitchcock, 1987; Fierro et al., 1990;
Rösche et al., 1996, 1997). According to our participants, EPPS did
not induce discomfort. Instead, they mentioned verbally a sensation of well-being. However, further work should address the otheraspects of the outcomes of long term Electrical Passive Cycling in
SCI veterans.
We suggest to conduct more studies with larger samples forevaluating the effect of passive cycling on spasticity, ROM andother muscle properties.

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Passive cycling effect in SCI

Conﬂict of Interest Statement: The
authors declare that the research was
conducted in the absence of any commercial or ﬁnancial relationships that
could be construed as a potential conﬂict of interest.
Received: 31 January 2011; accepted: 07
June 2011; published online: 20 June
2011.

Citation: Rayegani SM, Shojaee H,
Sedighipour L, Soroush MR, Baghbani M and Amirani OB (2011) The
effect of electrical passive cycling on
spasticity in war veterans with spinal
cord injury. Front. Neur. 2:39. doi:
10.3389/fneur.2011.00039
This article was submitted to Frontiersin Spinal Cord Medicine, a specialty of
Frontiers in Neurology.

Copyright © 2011 Rayegani, Shojaee,
Sedighipour, Soroush, Baghbani andAmirani. This is an open-access article subject to a non-exclusive license
between the authors and Frontiers MediaSA, which permits use, distribution andreproduction in other forums, provided
the original authors and source are credited and other Frontiers conditions arecomplied with.

June 2011 | Volume 2 | Article 39 | 7