Chronic Post-stroke Spasticity Research Articles

Splint efficacy in chronic post-stroke spasticity: a pilot study

IntroductionHand spasticity after stroke is a serious issue and may lead to hygiene problems, range of motion limitations, or contractures. Hand splints are often used to reduce spasticity and prevent movement limitations; however, there is little research available on the efficacy of splints in spasticity. The study aimed to investigate the efficacy of a reflex inhibitory splint (RIS) for upper extremity spasticity in stroke patients by using clinical and electrophysiological studies.MethodsStroke patients with elbow and hand spasticity were allocated into 2 groups. The splint group (<i>n</i> = 16) wore RIS. The control group (<i>n</i> = 13) did not wear any upper extremity splint. Both groups received the same rehabilitation program during this period. They were evaluated for motion in the upper extremity with the Brunnstrom scale and Fugl-Meyer upper extremity scale. Electrophysiological measurements showing motor neuron excitability such as the ratio between the maximum amplitude of H-reflex and the maximum amplitude of M-response (H<sub>max</sub>/M<sub>max</sub> ratio), H-reflex latency, and F-wave persistence and latency were also studied. All clinical and electrophysiological measurements were performed in both groups on days 0 and 15.ResultsAt the end of the treatment, elbow and finger flexion tonus decreased and active wrist extension angle increased in the splint treatment group compared with both baseline and the control group. Compared with the pre-treatment status, a correlation was detected between the H<sub>max</sub>/M<sub>max</sub> ratio and the wrist flexion tonus in the splint group.ConclusionsRIS may be useful for the management of post-stroke upper-limb spasticity.

Clinical evaluation and monitoring of the effect of extracorporeal shockwave therapy in sub-acute and chronic post-stroke spasticity patients

IntroductionTo evaluate the efficacy and maintenance of extracorporeal shockwave therapy (ESWT) in sub-acute and chronic post-stroke spasticity patients in the Suez Canal region.MethodsAn interrupted time series study was conducted; 82 patients were recruited in accordance with the defined inclusion and exclusion criteria. They were divided into 2 subgroups depending on the stroke duration: a sub-acute group (35 patients) and a chronic group (47 patients). ESWT was applied over knee and ankle flexor muscle belly with the following setup parameters: energy: 0.068–0.093 mJ/mm; frequency: 5 Hz; number of shots: 1500. Modified Ashworth score, clonus score, 3-minute walk test, range of motion angle of both knee and ankle joint, and Fugl-Meyer Assessment were established at baseline, after the 1<sup>st</sup> session, and at the 1<sup>st</sup>, 4<sup>th</sup>, and 8<sup>th</sup> week for the 2 groups.ResultsRegarding the sub-acute group, there was a statistically significant improvement in the modified Ashworth score, clonus score, 3-minute walk test, and range of motion angle of both knee and ankle joint after the 1<sup>st</sup> session and after the 1<sup>st</sup> week of intervention. The differences were not statistically significant after 4<sup>th</sup> or 8<sup>th</sup> week. The chronic group showed no statistically significant improvement after the 1<sup>st</sup> session or in the 1<sup>st</sup>, 4<sup>th</sup>, or 8<sup>th</sup> week assessment.ConclusionsESWT was more effective in treatment of spasticity in patients with sub-acute stroke compared with those with chronic stroke.

The Effectiveness of Botulinum Toxin Type A (BoNT-A) Treatment in Brazilian Patients with Chronic Post-Stroke Spasticity: Results from the Observational, Multicenter, Prospective BCause Study.

Botulinum toxin type A (BoNT-A) is an effective treatment for post-stroke spasticity; however, some patients cannot access treatment until ≥1 year post-stroke. This Brazilian post-marketing study (NCT02390206) assessed the achievement of person-centered goals in patients with chronic post-stroke spasticity after a BoNT-A injection. Patients had a last documented stroke ≥1 year before study entry and post-stroke upper limb (UL) spasticity, with or without lower limb (LL) spasticity. Patients received BoNT-A injections at baseline (visit 1) and visit 2 (3–6 months). Primary endpoint was responder rate (achievement of primary goal from Goal Attainment Scaling (GAS)) at visit 2. Overall, 204 patients underwent GAS evaluation at visit 2, mean (SD) age was 56.4 (13.2) years and 90.7% had LL spasticity. Median (range) time between first stroke and onset of spasticity was 3.6 (0−349) months, onset of spasticity and first injection was 22.7 (0−350) months and waiting time for a rehabilitation appointment was 9.0 (1−96) months. At visit 2, 61.3% (95% CI: 54.4, 67.7) of patients were responders, which was similar for UL and LL primary goals (57.8% [95% CI: 49.9, 65.3] vs. 64.1% [95% CI: 48.4, 77.3]). This study provides evidence to support the effectiveness of BoNT-A treatment for chronic post-stroke spasticity.

IncobotulinumtoxinA Treatment in Upper-Limb Poststroke Spasticity in the Open-Label Extension Period of PURE: Efficacy in Passive Function, Caregiver Burden, and Quality of Life.

Poststroke spasticity affects motor function and the ability to perform activities of daily living, with the potential to affect quality of life (QoL) and increase caregiver burden. To investigate the effect of repeated incobotulinumtoxinA treatment on spasticity-associated functional disability, caregiver burden, and QoL in the 36-week open-label extension of the phase 3 PURE study (NCT01392300). Open-label extension period of a prospective, double-blind, placebo-controlled, randomized, multicenter study. Forty-six investigation sites in seven countries (Czech Republic, Germany, Hungary, India, Poland, Russia, United States). Adults, aged 18-80 years, ≥12 months since last botulinum neurotoxin injection or entirely toxin naïve, with median poststroke upper-limb spasticity of >2 years' duration. Participants who completed the 12-week, double-blind main period could enter the open-label extension and receive up to three additional incobotulinumtoxinA treatments (fixed total dose 400 U at 12-week intervals) into the affected muscles of one upper limb. Functional disability (Disability Assessment Scale; DAS), caregiver burden (Carer Burden Scale), and quality of life (QoL; EuroQol [EQ] 5-dimensions three-level [EQ-5D-3L]). The open-label extension included 296 treated patients. Mean DAS score for the principal target domain improved significantly from the main period baseline to the end-of-study visit (P < .0001). Carer Burden Scale scores also significantly improved from the main period baseline to the end-of-study visit (P < .05 for all caregiving activities except "applying a splint"). At the end-of-study visit, versus the main period baseline, 19.7%-33.3% of patients experienced improvements for each parameter on the EQ-5D-3L, except "mobility," with significant improvement in EQ-5D visual analog scale scores (P < .001). Repeated incobotulinumtoxinA treatments at 12-week intervals in participants with chronic poststroke upper-limb spasticity resulted in significant improvements in QoL, as well as significant reductions in upper-limb functional disability and caregiver burden.

Ultrasound Strain Imaging to Assess the Biceps Brachii Muscle in Chronic Poststroke Spasticity.

The aim of the study was to assess the feasibility of ultrasound strain imaging in characterizing the biceps brachii muscle in chronic poststroke spasticity. We prospectively analyzed strain imaging data from bilateral biceps brachii muscles in 8 healthy volunteers and 7 patients with poststroke chronic spasticity. Axial deformations of the biceps brachii muscle and overlying subcutaneous tissue were produced by external compression using a sandbag (1.0 kg) attached to a transducer. The lengthening and shortening of the biceps brachii muscle and subcutaneous tissue were produced by manual passive elbow extension (from 90° to 0°) and flexion (from 0° to 90°), respectively. We used offline 2-dimensional speckle tracking to estimate axial and longitudinal strain ratios (biceps brachii strain/subcutaneous tissue strain), and the longitudinal tissue velocity of the biceps brachii muscle. Statistical analyses included analysis of variance for testing differences in strain imaging parameters among healthy, nonspastic, and spastic biceps brachii muscles, the Bonferroni correction for further testing differences in US strain imaging among paired groups (healthy versus spastic, nonspastic versus spastic, and healthy versus nonspastic), and the Pearson correlation coefficient for assessing the intraobserver reliability of performing strain imaging in stroke survivors. The differences in strain imaging parameters between healthy and spastic and between nonspastic and spastic biceps brachii muscles were significant at both 90° elbow flexion and maximal elbow extension (P < .01). There was no significant difference in axial strain ratios at 90° of elbow flexion or longitudinal tissue velocities between healthy and nonspastic muscles (P > .05). The intraobserver reliability of performing strain imaging in stroke survivors was good (r = 0.85; P < .01). Ultrasound strain imaging seems to be feasible for characterizing the biceps brachii muscle in chronic poststroke spasticity.

Quantitative Ultrasound Imaging to Assess the Biceps Brachii Muscle in Chronic Post-Stroke Spasticity: Preliminary Observation

We prospectively investigated the feasibility of using quantitative ultrasound imaging (QUI) to assess the biceps brachii muscle (BBM) in individuals with chronic post-stroke spasticity. To quantify muscle echogenicity and stiffness, we measured QUI parameters (gray-scale pixel value and shear wave velocity [SWV, m/s]) of the BBM in three groups: 16 healthy BBMs; 12 post-stroke, non-spastic BBMs; and 12 post-stroke, spastic BBMs. The QUI results were compared with the Modified Ashworth Scale and Tardieu Scale. A total of 20 SWVs were measured in each BBM, once at elbow in 90° flexion and again at maximally achievable extension using acoustic radiation force impulse imaging. BBM pixel value was measured in gray-scale images captured at 90° elbow flexion using ImageJ software. Statistical analyses included analysis of variance for examining the difference in SWV and pixel values among the three groups; Bonferroni correction for testing the difference in SWV and pixel values in a paired group; t-test for examining the difference in SWV values measured at two elbow angles; and Pearson correlation coefficient for analyzing the correlation of QUI to Modified Ashworth Scale and Tardieu Scale. SWV significantly differed between spastic BBMs and non-spastic or healthy BBMs. For pixel values, each of the three groups significantly differed from the others at elbow 90° flexion. The difference in SWV measured between the two elbow angles was also significant (p < 0.01). A strong negative correlation was found between SWV and passive range of motion (R2 = −0.88, p < 0.0001) in spastic upper limbs. These results suggest that the use of QUI is feasible in quantitative assessment of spastic BBM.

Dry needling at myofascial trigger points mitigates chronic post-stroke shoulder spasticity.

Post-stroke spasticity is associated with restriction in the range of motion of the shoulder. Reducing muscular dystrophy may help relieve muscular dysfunction in patients with post-stroke shoulder spasticity. Dry needle therapy is a method of needling the trigger points using a syringe needle without the use of a drug. Dry needle therapy is commonly used for pain at the shoulder, neck, waist, and back. In this case study, a 62-year-old male patient affected with cerebral hemorrhage of the right frontal lobe had received rehabilitative treatment for 12 years. However, he still experienced shoulder spasticity. The patient received daily dry needling at the trigger points of infraspinatus, teres minor, posterior deltoid, and pectoralis major on 9 days. After the first and ninth treatment, the Modified Ashworth Scale and the passive range of motion of the shoulder was used to assess the effect of the treatment. The spasticity and range of motion of the shoulder showed obvious improvement. These results indicate that dry needling at the myofascial trigger points can effectively treat chronic post-stroke shoulder spasticity.

Stretch-reflex threshold modulation during active elbow movements in post-stroke survivors with spasticity

ObjectivesVoluntary movements post-stroke are affected by abnormal muscle activation due to exaggerated stretch reflexes (SRs). We examined the ability of post-stroke subjects to regulate SRs in spastic muscles. MethodsElbow flexor and extensor EMGs and joint angle were recorded in 13 subjects with chronic post-stroke spasticity. Muscles were either stretched passively (relaxed arm) or actively (antagonist contraction) at different velocities. Velocity-dependent SR thresholds were defined as angles where stretched muscle EMG exceeded 3SDs of baseline. Sensitivity of SRs to stretch velocity was defined as µ. The regression through thresholds was interpolated to zero velocity to obtain the tonic SR threshold (TSRT) angle. ResultsCompared to passive stretches, TSRTs during active motion occurred at longer muscle lengths (i.e., increased in flexors and decreased in extensors by 10–40°). Values of μ increased by 1.5–4.0. Changes in flexor TSRTs during active compared to passive stretches were correlated with clinical spasticity (r=−0.68) and arm motor impairment (r=0.81). ConclusionsSpasticity thresholds measured at rest were modulated during active movement. Arm motor impairments were related to the ability to modulate SR thresholds between the two states rather than to passive-state values. SignificanceRelationship between spasticity and movement disorders may be explained by deficits in SR threshold range of regulation and modifiability, representing a measure of stroke-related sensorimotor deficits.

Preliminary assessment of the benefits of combining incobotulinumtoxinA (Xeomin®) with conventional rehabilitation therapy on the function of people with chronic post-stroke spasticity

Preliminary assessment of the benefits of combining incobotulinumtoxinA (Xeomin®) with conventional rehabilitation therapy on the function of people with chronic post-stroke spasticity

Poster 366: Dose Response in Muscles Treated With Botulinum Neurotoxin Type A for Upper Limb Chronic Poststroke Spasticity: A Pooled-Data Analysis

Objective: To characterize dose-by-muscle treatment response in chronic poststroke spasticity patients treated with botulinum toxin type A (BTX-A; BOTOX, Allergan, Irvine, CA). Design: Pooled analyses from 7 double-blind, placebo-controlled trials. Setting: Multicenter clinical sites. Participants: Patients (N=576, mean age 59±13y, 48% women) with poststroke upper-limb spasticity. Interventions: 1 treatment of BTX-A at doses of 360U or less in the distal upper limb (including 200U in the wrist), with 12 weeks of followup.

Clinically meaningful differences of the Ashworth Scale in patients with chronic post-stroke upper limb spasticity treated with botulinum neurotoxin type A (botox ®)

We describe the clinical importance of changes in Ashworth Scale (AS) scores in chronic post-stroke spasticity patients. Data from 3 clinical trials including 442 patients were pooled and analyzed. Changes from baseline in the AS were compared to the Physician Global Assessment score (PGAS). Receiver Operator Curve (ROC) analyses with wrist flexor AS change from baseline as the independent variable and PGAS as the dependent variable were performed to estimate clinically meaningful changes in spasticity using the criteria for clinical meaningfulness of PGAS ⩾1 (mild improvement or better) and PGAS ⩾2 (moderate improvement or better). Pearson correlation for the change in wrist AS and PGAS was −0.44 (p=0, t=26.5), with correlations of −0.45 and −0.22 noted for the finger and elbow (p Study supported by: Allergan, Irvine, CA

Needle acupuncture in chronic poststroke leg spasticity

Fink M, Rollnik JD, Bijak M, Borstädt C, Däuper J, Guergueltcheva V, Dengler R, Karst M. Needle acupuncture in chronic poststroke leg spasticity. Arch Phys Med Rehabil 2004;85:667–672. Objective To determine whether needle acupuncture may be useful in the reduction of leg spasticity in a chronic state. Design Single-blind, randomized, placebo-controlled trial. Setting Neurologic outpatient department of a medical school in Germany. Participants Twenty-five patients (14 women) suffering from chronic poststroke leg spasticity with pes equinovarus deformity (Modified Ashworth Scale [MAS] score, ≥1), aged 38 to 77 years (mean ± standard deviation, 58.5±10.4y), were enrolled in the study. The mean time from stroke to inclusion in the study was approximately 5 years (mean, 65.4±48.3mo; range, 7–180mo). Interventions Participants were randomly assigned to placebo treatment (n=12) by using a specially designed placebo needling procedure, or verum treatment (n=13). Main outcome measures MAS score of the affected ankle, pain (visual analog scale), and walking speed. Results There was no demonstrated beneficial clinical effects from verum acupuncture. After 4 weeks of treatment, mean MAS score was 3.3±0.9 in the placebo group versus 3.3±1.1 in the verum group. The neurophysiologic measure of H-reflex indicated a significant increase of spinal motoneuron excitability after verum acupuncture (H-response/M-response ratio: placebo, .39±.19; verum, .68±.41; P<.05). Conclusions This effect might be explained by afferent input of A delta and C fibers to the spinal motoneuron. The results from our study indicate that needle acupuncture may not be helpful to patients with chronic poststroke spasticity. However, there was neurophysiologic evidence for specific acupuncture effects on a spinal (segmental) level involving nociceptive reflex mechanisms.