Complementary Therapies in Medicine (2014) 22, 10011009

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevierhealth.com/journals/ctim

Anti-spastic effects of footbaths in

post-stroke patients: A proof-of-principle
study
Shuji Matsumoto a,, Megumi Shimodozono a, Seiji Etoh a,
Tomokazu Noma b, Tomohiro Uema b, Keiko Ikeda b,
Kodai Miyara b, Nobuyuki Tanaka a, Kazumi Kawahira a
a

Department of Rehabilitation and Physical Medicine, Graduate School of Medical and Dental Sciences,
Kagoshima University, Kagoshima, Japan
b
Department of Rehabilitation, Kirishima Rehabilitation Center of Kagoshima University Hospital,
Kagoshima, Japan
Available online 30 September 2014

KEYWORDS
Footbath;
Spasticity;
Stroke;
F-wave;
Temperature

Abstract
Objectives: To investigate whether a footbath inhibits spasticity in the hemiplegic lower limbs
of post-stroke patients.
Design: Randomized, controlled study.
Setting: Rehabilitation education and research hospital.
Interventions: Twenty-two post-stroke patients were randomly allocated to control or experimental groups. After relaxing in a supine posture for 30 min, the experimental group subjects
legs were immersed in 41 C water below the knee joint for 15 min, while the control group
remained in a resting posture.
Main outcome measures: Modied Ashworth Scale (MAS) scores of the affected triceps surae
muscle and F-wave parameters (i.e., F-wave amplitude, F/M ratio, and F-wave persistence)
were recorded before, immediately after, and 30 min after each intervention. Physiological
parameters were simultaneously monitored to determine the thermo-therapeutic mechanisms
and side effects of footbath usage.
Results: At the time immediately after the intervention, F-wave amplitudes decreased signicantly in the experimental group, compared to the control group (p < 0.01, difference:
106.8; 95% CI; 181.58 to 32.09). F-wave amplitudes decreased signicantly after 30-min
intervention in the experimental group, with a total reduction of 161.2 V being recorded compared to 8.8 V increase in the control group (p < 0.01, difference: 170.0; 95% CI; 252.73 to
87.33). There were also signicant differences between the experimental and control group
for both F/M ratio and F-wave persistence, immediately after and 30 min after the intervention.
Further, there were signicant differences between the experimental and control group for the

Corresponding author. Tel.: +81 995 78 2538; fax: +81 995 64 4045.
E-mail address: shushusa71@yahoo.co.jp (S. Matsumoto).

http://dx.doi.org/10.1016/j.ctim.2014.09.006
0965-2299/ 2014 Elsevier Ltd. All rights reserved.

1002

S. Matsumoto et al.
MAS scores immediately after the intervention (p < 0.05, difference: 0.72; 95% CI; 1.262
to 0.193), and 30 min after the intervention (p < 0.05, difference: 0.73; 95% CI; 1.162 to
0.293).
Conclusion: These ndings demonstrate that the use of footbaths is an effective nonpharmacological anti-spastic treatment for use in stroke rehabilitation.
2014 Elsevier Ltd. All rights reserved.

Introduction
Spasticity, a type of hypertonicity, is an increase in muscle tone due to hyperexcitability of the stretch reex and
is characterized by a velocity-dependent increase in tonic
stretch reexes.1 Spasticity is a common phenomenon that
often develops after an upper motor neuron lesion such
as stroke, multiple sclerosis, or spinal cord injury. In this
regard, spasticity can be a signicant cause of disability
after stroke. Increased muscle tone of the lower limbs is a
major obstacle during post-stroke hemiplegia rehabilitation
that can seriously impair gait stability and activities of daily
living (ADL), even if the hemiplegia is relatively mild.2,3 In
addition, spasticity in the affected limbs often inhibits the
efcacy of physiotherapy for the treatment of stroke.3,4 It
is therefore very important to control spasticity, especially
during physiotherapy, to improve lower limb movements.
Although spasticity is difcult to quantify and treat, many
previous studies have investigated spasticity in post-stroke
hemiplegia patients. The modied Ashworth scale (MAS),5 in
terms of assessment of resistance to passive movement, is
the most common clinical measure for spasticity. However,
electromyographic examination and biomechanical analyses
of limb resistance to passive movement have recently been
found to be reliable and valid.6 Conventional electromyographic methods to quantify spasticity, such as the H-reex7
and the T-reex8 , require specialized technical skills and
lack reproducibility. Furthermore, the complexity of these
methods make it difcult to observe spastic changes after
various load tests such as muscle stretching, gait exercise,
and medication.
In contrast, F-waves can be recorded from small hand
and foot muscles upon supramaximal electrical stimulation
of the appropriate mixed peripheral nerves9 and can be used
to study long-pathway nerve conduction and motor-neuron
excitability. F-waves measured by electromyographic examinations could be an indicator of alpha motor-neuron
excitability,10,11 and spasticity-induced alterations in F-wave
parameters have been conrmed in experimental animals.12
The F-wave amplitude, F-wave/M-response amplitude ratio
(F/M ratio; the M-response is the direct motor potential), and F-wave persistence are considered to reect
motor-neuron excitability (i.e., spasticity).10,11 The F-wave
amplitude was found to change in parallel with muscle
tone after an acute cerebral insult13 and was reduced by
treatment with tizanidine, baclofen, myolastan, or electroacupuncture in cases of post-stroke hemiplegia.14,15 Thus,
these F-wave parameters are more sensitive to changes in
lower motor-neuron excitability during the course of spasticity than both the T- and H-reexes.13,14,16,17
The management of spasticity remains a major challenge in rehabilitation medicine. The available treatment

options include various physical methods (e.g., muscle

lengthening, splinting, and electrostimulation), systemic
use of spasmolytic drugs, and several invasive procedures
for focal neuronal or neuromuscular blockade.18,19 Interestingly, thermotherapy has been reported to decrease
muscle tone, reduce muscle spasms, and increase the pain
threshold in patients with muscle hypertonia.20 Because
thermotherapy is non-invasive, its incorporation into exercise regimes may inhibit the spasticity of hemiplegic
patients.21,22
We found that thermotherapy applied to the spastic
muscles of post-stroke patients suppressed spasticity after
continuous warm-water immersion for 1015 min.23,24 Our
pilot data suggested that a footbath improved the pathological increases in muscle tone and did not have side effects.
However, it was unclear from our before-and-after trial
whether the anti-spastic activity effect of a footbath could
be partially attributed to the effects of resting. The aim of
the present study was to elucidate the anti-spastic effects
of a footbath for spastic hyper-reexic patients by using
F-wave parameters and MAS scores.

Methods
Subjects
Twenty-two post-stroke patients with lower limb spasticity were recruited from inpatients admitted to the
Kirishima Rehabilitation Centre of Kagoshima University,
Japan, between April 1, 2008 and March 31, 2010. The diagnosis of stroke was based on a computed tomography (CT)
scan or magnetic resonance imaging (MRI), as well as neurological functions.
The inclusion criteria were as follows: 3070 years of
age; increased muscle tone of the affected lower limb (MAS
score 1); hemiplegia of the lower limb (Brunnstrom stage25
35); could walk without assistance using a T-cane and/or
ankle foot orthosis; receiving no stimulant or relaxant
medications (including anti-spasticity and anti-convulsion
medications or pharmacological injections); and normal Fwave and M-response latencies, indicating no peripheral
nerve injury.
The exclusion criteria were as follows: onset of stroke
<4 weeks previously; abnormal gait prior to the onset of
stroke (such as joint disability or peripheral neuropathy);
any medical condition that limited footbath usage (such as
severe cardiopulmonary disease or severe sensory disturbance); severe aphasia that made it impossible to follow
verbal instructions; lesions on both sides of the cerebral
hemisphere; and dementia that interfered with the outcome
assessments.

Anti-spastic effects of footbaths in post-stroke patients: A proof-of-principle study

The study was conducted without altering the existing
medication regimes of the patients. The procedures used in
this study complied with the 1975 Declaration of Helsinki, as
revised in 1983. Informed consent was obtained from each
subject according to the ethical guidelines of the hospital
after they fully understood the purpose and methodology.
This study was carried out with the permission of the Ethical
Committee of Kagoshima University.

Experimental procedure
The principal investigator (S. M.) was responsible for
eligibility assessment, consent, baseline assessment, and
performance of all participants. All outcome assessments
were completed by 1 another physician and 1 physiotherapist who were masked to treatment allocation. All subjects
participated at the same time of day (14:0016:00) after
they had eaten a meal. Subjects who satised the inclusion
criteria were randomly allocated to an experimental or control group. Randomization was accomplished in a centralized
manner using a computer-generated random number that
did not take a participants location into account. Evaluators were blinded to a participants treatment assignment,
and participants were unaware of the studys hypotheses.
After relaxing for 30 min in the supine posture with the
lower limb extended on a lift-bath stretcher, the subjects
received the interventions for 15 min. Each subject wore
only underwear during the rest periods but was kept warm
using two blankets. Physiological parameters, electromyographic responses (F-wave), and MAS scores were monitored
before, during, and 30 min after the intervention sessions.

Interventions
Footbath treatment was performed according to the guidelines of the Japanese Association of Physical Medicine,
Balneology, and Climatology. The footbath treatment settings were selected based on the results of our previous
study.24 Footbath sessions in 41 C water are customary in
Japan, and this procedure has been shown to be comfortable and does not induce sympathetic hypertonia or
dehydration.26,27
In the experimental group, once stable baseline F-wave
measurements and a physiological examination had been
obtained, a bathtub (135 L volume, 45-cm width, 68-cm
length, 45-cm depth; Ejector Bath HK-22; OG Giken Co. Ltd.,
Japan) was prepared, and the subject was immersed in the
water up to the knee joint level. The bath jet was switched
off during the study period. A thermostat was used to maintain the temperature at 41 C 0.1 C. Each footbath session
was 15 min in length, during which the subject was kept
at rest in a seated position. After completion of the footbath treatment, the subjects legs were withdrawn and were
dried thoroughly with a towel. The subjects in the control
group sat in a relaxed posture for 15 min with the hip and
knee joint angles at approximately 90 of exion and the
ankle joint angles at 0 of dorsiexion.
The measurement of F-waves and a physiological examination were carried out immediately (within 5 min) after the
intervention session and again 30 min later, while the subject
remained wrapped in blankets on the lift-bath stretcher.

1003

Electromyographic examination: F-wave study

For the electrophysiological studies, each subject lay in the
supine position with both legs supported in a relaxed position
in a semi-darkened air-conditioned room with a constant
ambient temperature of 25 C. A one-channel recording from
the triceps surae muscle allowed instantaneous comparison
of simultaneously evoked F-waves in the spastic muscle, to
evaluate the effect of footbath.10,28
We used a Nihon-Kohden Neuropack system (Nihon Koden
Co. Ltd., Japan) with a band-pass lter of 10 Hz to 10 kHz
and a sensitivity set at 5 mV and 200 mV/division to record
compound muscle action potentials (CMAPs) and F-waves,
respectively. Paired Ag AgCl surface electrodes were taped
to the belly and tendon of the triceps surae muscle after lowering the skin resistance to less than 5 k. The tibial nerve
was stimulated at 1 Hz with a rigid bar electrode strapped
securely at popliteal fossa, with the cathode positioned 3 cm
proximally from the popliteal crease. Stimuli were 0.1 ms
in duration and ranged from 10 to 50 mA when set at an
intensity of 20% higher than that at which the largest CMAPs
could be elicited.13,16 A total of 100 F-waves were recorded
following supramaximal current pulses. A stainless-steel surface electrode placed on the dorsum of each subjects ankle
served as a ground electrode.
Peak-to-peak measurements were made of the Mresponse amplitude and that of the 100 averaged
F-responses (F-wave amplitude) for each lower limb before
and after the intervention. In addition to recording the Fwave and M-response amplitudes, we calculated the ratio
of the F-wave amplitude to the M-response amplitude (the
F/M ratio) and the F-wave persistence.

Measurement of muscle tone

The extent of spasticity was measured using the MAS score5
for the triceps surae muscle of the calf. The MAS is an established and widely used clinically test, which uses a 6-point
scale to score the average resistance to passive movement
for each joint. A MAS of 0 indicates no increase in muscle tone, while a MAS of four indicates that the affected
part(s) is rigid in exion or extension. To facilitate data
analysis, the MAS scores (0, 1, 1+, 2, 3, and 4) were assigned
numerical values designated as computed MAS scores (0,
1, 2, 3, 4, and 5).29,30 Changes in the MAS scores were
calculated by the subtraction method. The evaluator was
a trained physiotherapist who was blinded for the group
assignment of each subject.

Physiological examination
The following physiological parameters were simultaneously
monitored to determine the thermotherapeutic mechanism
and side effects of footbath usage: body temperature, surface skin temperature, intermittent blood pressure, and
heart rate. A deep body thermometer probe, 2 mm in diameter (electric thermistor; CTM303; Terumo Co., Ltd., Tokyo,
Japan), was taped onto the hypoglottis (under the tongue). A
surface skin temperature probe (1.5-cm diameter) was xed
in the same way onto the belly of the quadriceps muscle of
the thigh and the belly of the abductor halluces muscle.

1004

S. Matsumoto et al.

Enrollment

Assessed for eligibility (n= 132)

Excluded (n= 110)

Not meeting inclusion criteria (n= 98)
Declined to participate (n= 12)
Other reasons (n= 0)

Randomized (n= 22)

Allocation
The experimental group (n= 11)
Received allocated intervention (n= 11)

The control group (n= 11)

Received allocated intervention (n= 11)

Did not receive allocated intervention (give

reasons) (n= 0)

Did not receive allocated intervention (give

reasons) (n= 0)

Follow-Up
Lost to follow-up (give reasons) (n= 0)

Lost to follow-up (give reasons) (n= 0)

Discontinued intervention (give reasons) (n= 0)

Discontinued intervention (give reasons) (n= 0)

Analysis
Analysed (n= 11)
Excluded from analysis (give reasons) (n= 0)

Analysed (n= 11)

Excluded from analysis (give reasons) (n= 0)

Fig. 1 The owchart diagram of progress through the various phases of this two-arm randomized trial according to CONSORT,
which stands for consolidated standard for reporting trials. Abbreviation: CONSORT, consolidated standards reporting of trials.

Blood pressure and heart rate measurements were made

using an automatic sphygmomanometer (GP303S: Paramatek
Co., Ltd., Fukuoka, Japan) based on oscillometric measurements.

and Brunnstrom stage of the lower limb were not signicantly between the two groups at baseline (Table 1). The
baseline F-wave amplitude, F/M ratio, F-wave persistence,
M-response, and MAS score for the triceps surae muscle were
also similar between groups (Table 2).

Statistical analysis
All values are given as mean standard deviation (SD). Statistical analyses were performed using a paired Wilcoxon
test or analysis of variance (ANOVA). Probability (p) values
below 0.05 were considered statistically signicant. All statistical analyses were performed using IBM SPSS Statistics
18.0 (SPSS Inc., Chicago, IL, USA).

Results
Patient baseline characteristics
The ow chart of the interventions is shown in Fig. 1. A total
of 132 candidates were screened between April 1, 2008 and
March 31, 2010.
The characteristics of the patients including age, sex,
Diagnosis, Hemiplegic side, Time since onset of stroke,

F-waves
Fig. 2 shows the changes in F-wave parameters after each
intervention. The F-wave amplitudes of the control subjects before, immediately after, and 30 min after rest were
691.5 265.8, 645.1 289.2, and 700.3 259.8 V, respectively, and those of the experimental group subjects were
694.6 231.8, 541.4 195.6, and 533.4 182.5 V, respectively.
The F-wave amplitude, F/M ratio, and F-wave persistence in the experimental group decreased markedly below
baseline levels after footbath treatment (p < 0.01). Although
all of them showed a tendency to return toward baseline
over time, they remained signicantly lower than the baseline even 30 min after the footbath (Fig. 2).
The F-wave amplitudes decreased signicantly immediately after the intervention in the experimental group,

Anti-spastic effects of footbaths in post-stroke patients: A proof-of-principle study

Table 1

Table 2

Baseline characteristics of the patients.

Age, years,
median (range)
Sex, male/female
(n)
Diagnosis, infarction/hemorrhage
(n)
Hemiplegic side,
right/left (n)
Time since onset
of stroke,
weeks, median
(range)
Brunnstrom stage
of the lower
limb, median
(range)

Control group
(n = 11)

Experimental
group (n = 11)

54 (3669)

56 (3868)

8/3

7/4

6/5

7/4

13 (630)

13 (632)

4 (35)

4 (35)

b. F/M ratio

3.46 0.91
97.4 2.5

3.44 1.11
97.6 2.5

21.4 6.9
2.2 0.8

21.4 5.7
2.3 0.9

c. F-wave persistence

-10

-10

-10

-20

-20

-20

-30

-30

-30

-40
30 min
after

694.6 231.8

The mean MAS scores of the affected triceps surae muscle

of the calf in the experimental group before, immediately after, and 30 min after footbath treatment were
2.3 0.9, 0.9 0.8, and 1.4 0.9, respectively. These values decreased markedly below baseline values immediately
after footbath treatment (p < 0.01). Although the values
showed a tendency to increase over time, they remained
signicantly below the baseline, even 30 min after footbath
usage (p < 0.05). Although the MAS score decreased significantly from 2.2 0.8 to 1.5 0.8 (p < 0.05) in the control

(%)
10

Immediately
after

691.5 265.8

MAS scores

(%)
10

Before

Experimental
group (n = 11)

intervention (p < 0.01, difference: 18.2; 95% CI; 23.05 to

13.32), and 30 min after the intervention (p < 0.05, difference: 14.3; 95% CI; 17.75 to 10.80).
The M-response was not altered following the intervention in either group, despite the marked changes in F-wave
parameters.

(%)
10

-40

Control group
(n = 11)

MAS: modied Ashworth scale.

compared to the control group (p < 0.01, difference: 106.8;

95% CI; 181.58 to 32.09). Further, F-wave amplitudes also
decreased signicantly after 30-minutes intervention in the
experimental group, with a total reduction of 161.2 V being
recorded compared to 8.8 V increase in the control group
(p < 0.01, difference: 170.0; 95% CI; 252.73 to 87.33).
There were signicant differences between the experimental and control group for F/M ratio immediately after
the intervention (p < 0.01, difference: 0.62; 95% CI; 1.172
to 0.068), and 30 min after the intervention (p < 0.01, difference: 0.85; 95% CI; 1.380 to 0.311). There were
also signicant differences between the experimental and
control group for F-wave persistence immediately after the

a. F-wave amplitude

Baseline F-wave parameters and MAS scores.

F-wave amplitude
(V)
F/M ratio (%)
F-wave
persistence %
M-response (mV)
MAS score for the
triceps Surae
muscle

7/4

6/5

1005

Rest
Footbath

-40
Before

Immediately
after

30 min
after

Before

Immediately
after

30 min
after

Fig. 2 The percentage changes in F-wave parameters. The F-wave amplitude, F/M ratio, and F-wave persistence decreased
signicantly after the footbath and remained below the baseline, even after 30 min. ; Control group, ; Experimental group.
Signicant differences: * p < 0.01, ** p < 0.05.

1006
group immediately after rest, these values returned to near
baseline levels 30 min later (2.0 1.1).
At the time immediately after the intervention, the
experimental group had lost 1.4 in the MAS scores, compared to only 0.6 decrease in the control group (p < 0.05,
Difference: 0.72; 95% CI; 1.262 to 0.193). The experimental group had lost 0.91 compared to 0.18 decrease in the
control group in the MAS scores (p < 0.05, difference: 0.73;
95% CI; 1.162 to 0.293) 30 min after intervention.

Physiological examination
Table 3 summarizes the physiological measurements taken
before, immediately after, and 30 min after the intervention. The body temperature rose signicantly from
36.2 C 0.3 C to 36.7 C 0.3 C in the experimental group
immediately after the 15-min footbath session and remained
signicantly higher than baseline, even 30 min after the
footbath. Similarly, the surface skin temperature increased
signicantly after the footbath session in the experimental group. The body and surface skin temperatures did not
signicantly change in the control group participants.
There were no signicant changes in systolic or diastolic
blood pressure following the intervention, with no signicant differences between the two groups. Heart rate tended
to increase above baseline immediately after footbath usage
in the experimental group and returned to near baseline levels 30 min later, with no signicant differences between the
two groups. No side effects of footbath usage were observed
during the physiological examination.
None of the subjects experienced discomfort before, during, or after each intervention. The electromyographic and
physiological examinations were completed safely in all subjects.

Discussion
We compared the efcacy of a footbath with that of a resting
condition using randomized, controlled methods. Changes in
spasticity were assessed using F-wave parameters and MAS
scores. Our results show a reduction in the F-wave amplitude, F/M ratio, and F-wave persistence after the footbath,
as well as improvements in the MAS scores for the triceps
surae muscle of the calf. There were statistically signicant
differences between the experimental and control groups.
In addition, the anti-spastic effect of the footbath on both
the F-wave parameters and MAS scores for the triceps surae
muscle remained after 30 min.
Spasticity is found in the majority of post-stroke patients.
There are several thermal therapeutic techniques for the
treatment of spasticity;31 therefore, an electrophysiological evaluation of their effects, as this might be helpful
in deciding which technique will be most benecial for
the post-stroke patient. Thus, in the current study, the
rst outcome measure for the assessment of spasticity was
an electromyographic examination using F-wave parameters and the second outcome measure was MAS scores.
We conrmed that footbath usage decreased spasticity, as
indicated by a decrease in F-wave parameters and MAS.
A one-point reduction in the MAS scores, as demonstrated
by the experimental group in the present study, has been

S. Matsumoto et al.
previously reported; this reduction is an indicator of
improved lower limb motor function and locomotion ability
in post-stroke patients.32,33 Furthermore, the F-wave parameters showed equivalent reductions to those in our previous
pilot study,3436 which indicated improved motor function
(e.g., active range of motion). These ndings suggest that
the anti-spastic effects of a footbath have clinical signicance.
The development of validated and reliable outcome
measures for spasticity control have been hampered by the
difculties involved in quantifying functionally important
parameters, including pain, ease of care, and mobility.37
Recently, F-wave parameters (F-wave amplitude, F/M ratio,
and F-wave persistence) were proposed as an objective
and precise method to evaluate changes in motor-neuron
excitability in spasticity. Several different mechanisms
might have led to the alterations in F-wave parameters
observed in the present study. However, our results clearly
showed a marked reduction of the F-wave amplitude, F/M
ratio, and F-wave persistence after footbath treatment,
indicating a reduction in motor-neuron excitability, in parallel with a decrease in the MAS scores.
When the subjects were immersed in warm water at
41 C, a continuous increase in body temperature was
observed, and the thermal comfort appeared to be related
to changes in spasticity status. These results were in agreement with those reported previously.24,27,38 This effect was
probably caused either by heat transportation through the
blood circulation or by direct heat conduction. Interestingly, the degree of the footbath-induced body temperature
increase was approximately half that of a whole-body warmwater bath,23 as was the reduction of F-wave parameters.
An increase in body temperature appears to play an important role in decreasing spasticity, and the mechanisms by
which it alters F-wave parameters are likely to be complex.
Thermal therapy is thought to have anti-spastic effects that
are not only due to relaxation of muscular and other soft
tissues, but also due to decreases in gamma-afferent ber
activity through a nervous system response. This process
is believed to cause a decrease in impulses from the muscle spindles to afferent bers, which consequently inhibits
impulses to the alpha bers. This could explain the observed
changes in F-wave parameters. That is, a greater number
of larger motor neurons are participating in the discharge,
and this phenomenon is the cause of the increased F-wave
parameters.39 Therefore, the changes observed after footbath treatment might be due to decreased motor-neuron
excitability.40 Further studies will be necessary to determine
whether footbath usage changes F-wave parameters according to the degree and type of spasticity. Additional studies
on the effects of local thermal therapy21 and sauna baths,41
which are expected to have similar anti-spastic effects to
whole-body warm-water baths, in the treatment of spasticity of hemiplegic limbs are also needed.
One major reason for the use of thermal therapy in poststroke patients with spasticity is that it has been suggested
to decrease muscle tone and facilitate neuromuscular function of upper42 and lower limbs.43 However, care must be
taken when applying this method, because some patients
can experience sensory disturbance in their affected side
or other complications. Therefore, in the present study,
the effects of thermally induced sympathetic hypertonia

Anti-spastic effects of footbaths in post-stroke patients: A proof-of-principle study

Table 3

1007

Physiological measurements before and after the intervention.

Control group
(n = 11)
Immediately
after

30 min after

36.1 0.5

36.2 0.6

36.2 0.6

36.2 0.3

36.7 0.3**,

36.6 0.3**,

32.0 1.5

32.3 1.3

32.2 1.6

31.6 1.3

32.8 1.6**,

32.2 1.5*

30.9 1.4

31.1 1.3

31.0 1.4

30.8 1.4

32.8 1.6**,

31.5 1.5*

124.5 11.7

124.4 10.6

124.9 10.4

126.9 12.5

75.3 11.3

75.0 10.8

75.9 9.7

78.1 12.8

76.2 10.3

78.5 10.9

70.5 7.2

70.3 6.5

69.7 6.1

69.6 8.5

73.5 8.2

69.5 6.7

Before
Body temperature
( C)
Surface skin
temperature of the
thigh ( C)
Surface skin
temperature of the
ankle ( C)
Systolic blood
pressure (mmHg)
Diastolic blood
pressure (mmHg)
Heart rate (bpm)

Experimental
group (n = 11)
Before

Immediately
after

124.5 7.9

30 min after

126.2 7.6

p < 0.05, signicantly different from the control group.

p < 0.05 Compared with baseline values.
** p < 0.01 Compared with baseline values.
*

and other footbath-related activities (potential side effects)

were minimized. The temperature of the footbath was maintained at a comfortable 41 C, as Japanese subjects prefer a
warm footbath and no physiological changes (no side effects)
have been reported at this temperature,26,44,45 and physical
activity was limited by aiding the subjects when entering
or leaving the footbath. A previous study on thermotherapeutic physiotherapy used a thermal spa,43 global heating23
at 41 C for 10 min, footbath treatment at 3842 C for
15 min with exercise,24,27 and the present study used similar methods to that applied in clinical settings. Yamamoto
et al.38 reported that footbath usage is an effective method
of relaxation, since it induces both a signicant increase
and decrease in parasympathetic and sympathetic activity, respectively. As none of our subjects complained of
excessive heat stimulation, we believe that use of a comfortable/relaxable water temperature and optimized treatment
duration resulted in minimal heat stress physiological stimulation (Table 3).
Resting (i.e., relaxation) is commonly used in the physical management of spasticity, and there is evidence to
support its immediate effects.46 Prolonged resting/relaxing
elicits a particularly notable effect.33,34 However, the antispastic effects of resting in the present study were observed
only immediately after treatment, probably due to the short
duration (5 min) of the intervention. These ndings indicate
that the effects of the footbath were not attributable to the
benets of resting.
Some of the strengths of this study in terms of validity were, rstly, it implemented by F-wave measurements,
therefore has a high methodological quality assessment in
the anti-spastic treatments. Secondly with regards to the
study design, this study is the rst investigation into the antispastic effects of footbath treatment in post-stroke patients
using randomized, controlled methods. A single principal
investigator and single outcome assessor throughout this

study reduced the risk of variations in technique and assessments. However, several limitations of the present study
should be acknowledged. First, future studies with a larger
number of participants are needed to conrm our results
with a small number of participants. Second, only spasticity
was assessed, and therefore, future studies should evaluate
motor function, ADL, and quality of life to clarify the contribution of footbaths to stroke rehabilitation. Finally, we evaluated the F-wave persistence and MAS scores for the triceps
surae muscles for 30 min after the footbath, and additional
investigations are necessary to conrm the anti-spastic duration of the footbath in a long-term follow up study.
In conclusion, our results provide evidence of the antispastic effects of thermal therapy in the hemiplegic lower
limbs of post-stroke patients and indicate that the efcacy
of a footbath cannot be attributed to the effects of resting.
Footbaths could have clinical applicability by providing a
non-pharmacological and convenient anti-spastic therapy in
post-stroke patients.

Conict of interest statement

None.

Sources of funding
All authors have no funding support.

Acknowledgments
None.

1008

Appendix A. Supplementary data

Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.ctim.2014.09.006.

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