Post-stroke Spasticity Management Research Articles

Long-Term Management of Post-Stroke Spasticity with Botulinum Toxin: A Retrospective Study

Stroke-induced spasticity is a prevalent condition affecting stroke survivors, significantly impacting their quality of life. Botulinum Toxin A injections are widely used for its management, yet the long-term effects and optimal management strategies remain uncertain. This retrospective study analyzed medical records of 95 chronic stroke patients undergoing long-term BoNT-A treatment for spasticity. Demographic data, treatment duration, dosage variability, and dropout rates were assessed over a period ranging from 2 to 14 years. The study revealed a notable extension of the interval between BoNT-A injections throughout the treatment duration. Dropout rates peaked during the initial 5 years of treatment, perhaps due to perceived treatment ineffectiveness. Additionally, a trend of escalating dosage was observed across all groups, indicating a potential rise in the severity of spasticity or changes in treatment response over time. BoNT-A injections emerged as the predominant treatment choice for managing post-stroke spasticity. The delayed initiation of BoNT-A treatment underscores the need for heightened awareness among healthcare providers to recognize and manage spasticity promptly post-stroke. Patients’ expectations and treatment goals should be clearly defined to optimize treatment adherence, while the observed escalation in dosage and treatment intervals emphasizes the dynamic nature of spasticity and underscores the importance of monitoring long-term treatment outcomes.

Immediate effects of dry needling on spasticity-related parameters in the wrist and elbow of patients after a stroke: a quasi-experimental feasibility study

Background/Aims Dry needling is widely used to treat myofascial pain and related musculoskeletal conditions. Recently, the use of dry needling for the management of post-stroke spasticity has been proposed. The aim of this study was to evaluate the immediate effect of dry needling of spastic muscles on pain, spasticity, and pain pressure threshold in the elbow and wrist muscles of patients who have had a stroke. Methods This quasi-experimental, pre–post design feasibility study implemented dry needling in wrist or elbow flexors. Outcome measures evaluated muscle spasticity using the Modified Modified Ashworth Scale, pain pressure threshold and range of motion. Results A total of eight participants (seven men and one woman) were included in the study. The average age was 57.00 ± 13.88 years. The Modified Modified Ashworth Scale scores decreased from 1.81 ± 0.84 to 1.25 ± 0.46 in the elbow flexors (P=0.066) and from 1.86 ± 0.69 to 1.29 ± 0.49 in the wrist extensors (P=0.046). Range of motion increased in the elbow, and there was a statistically significant increase in the range of motion in the wrist (P=0.027). Pain pressure threshold also increased statistically significantly in muscles related to the wrist and elbow (P=0.043 and P=0.035 respectively). Conclusions Dry needling may decrease spasticity, increase range of motion and pain pressure threshold in treated muscles and improve functional gains in the spastic limb. Further, more extensive studies are essential to assess the use of dry needling in managing post-stroke spasticity. Implications for practice Physiotherapists can use dry needling in spastic muscles when treating patients who have had a stroke.

Characterizing clinical patterns of physical therapy activities for post-stroke spasticity in stroke rehabilitation: looking into the "Black Box".

Physical therapy is considered to be an adjunctive therapy for the management of post-stroke spasticity. The insight of this study is to observe the current clinical practices of rehabilitation for post-stroke spasticity. For this purpose, an observational cross-sectional study was conducted. Data was collected by a standardized therapy documentation form for spasticity management. Fifty physiotherapists filled out that form. Almost all of them used subjective measures (modified Ashworth scale) for spasticity assessment and functional independence measure for level of independence. Readings were taken in the first, second, and third blocks of six-hour duration. Results showed that 42 (83.5%) physiotherapists measured spasticity at the initial session, while 47(94.6%) reported various multiple rehabilitation treatment preferences for spasticity management. Disparities exist in therapeutic management for post-stroke spasticity throughout rehabilitation which are mainly based on physiotherapists' clinical expertise. However, a better understanding of current trends in physical therapy clinical practices will assist in tailoring strategies to upgrade management for post-stroke spasticity.

Selecting Goals and Target Muscles for Botulinum Toxin A Injection Using the Goal Oriented Facilitated Approach to Spasticity Treatment (GO-FAST) Tool.

The objective of this article is to introduce the GO-FAST Tool (developed by the Toxnet group) to clinicians working in the field of neurological rehabilitation, specifically post-stroke spasticity management. The concepts utilized in the Tool and described in this article can be broadly grouped into five topics: the principles of patient-centred goal-setting; an algorithm for setting SMART (specific, measurable, attainable, realistic, and timed) treatment goals; goal-related target muscles and botulinum toxin type A dose determinants; goal attainment follow-up, scoring, and interpretation; and the multimodal approach to spasticity management. The Tool can enhance clinical practice by providing guided assistance with goal-setting and target muscle selection for botulinum toxin type A treatment. It also provides support with the follow-up evaluation of goal attainment and calculation of treatment success. The Tool is designed to be used by clinicians with varying levels of expertise in the field of neurological rehabilitation and post-stroke spasticity management, from those who are new to the field to those with many years of experience. A case study is presented in the Results Section of the article to illustrate the utility of the Tool in setting SMART treatment goals in the management of patients with post-stroke spasticity.

Healthcare resource utilization and costs among patients with post-stroke spasticity before and after spasticity management including onabotulinumtoxina.

Real-world data regarding the impact of onabotulinumtoxinA on healthcare resource utilization and costs for post-stroke spasticity are scarce. To compare differences in 12-month healthcare resource utilization and costs before and after post-stroke spasticity management including onabotulinumtoxinA. This retrospective claims analysis of IBM MarketScan Commercial and Medicare Supplemental databases included adults with ≥ 1 onabotulinumtoxinA claim for post-stroke spasticity (1 January 2010 to 30 June 2018) and continuous enrolment for ≥ 12 months pre- and post-index (first onabotulinumtoxinA claim date). All-cause and spasticity-related healthcare resource utilization and costs were compared 12 months pre- and post-index (McNemar's χ2 test or paired t-test). A subgroup analysis assessed effect of stroke-to-index interval on costs. Among 735 patients, mean (standard deviation) stroke-date-to-index-date interval was 284.5 (198.8) days. Decreases were observed post-index for mean all-cause outpatient (62.9 vs 60.5; p ≤ 0.05) and emergency department visits (1.1 vs 0.8; p ≤ 0.0001), and hospital admissions (1.5 vs 0.4; p ≤ 0.0001). Increase in prescription fills (43.0 vs 53.7) was seen post-index. Post-index decreases in all-cause (-66%) and spasticity-related (-51%) costs were driven by reduced inpatient care costs. Findings were consistent regardless of stroke-date-to-index-date interval. Significant reductions in healthcare resource utilization and costs were observed after 1 year of post-stroke spasticity management including onabotulinumtoxinA. Long-term studies are needed to establish causality.

Canadian Physicians' Use of Intramuscular Botulinum Toxin Injections for Shoulder Spasticity: A National Cross-Sectional Survey.

Spasticity of the upper extremity can result in severe pain, along with many complications that can impair a patient's activities of daily living. Failure to treat patients with spasticity of the upper limb can result in a decrease in the range of motion of joints and contracture development, leading to further restriction in daily activities. We aimed to investigate the practice patterns of Canadian physicians who utilize Botulinum toxin type-A (BoNT-A) injections in the management of shoulder spasticity. 50 Canadian Physical Medicine and Rehabilitation (PM&R) physicians completed a survey with an estimated completion rate of (36.23%). The demographics of the survey participants came from a variety of provinces, clinical settings, and patient populations. The most common muscle injected for shoulder adduction and internal rotation spasticity was the pectoralis major, this was followed by latissimus dorsi, pectoralis minor, subscapularis and teres major. Injection of BoNT-A for problematic post-stroke shoulder spasticity was common, with (81.48%) of participants responding that it was always or often used in their management of post-stroke spasticity (PSS). Dosing of BoNT-A demonstrated variability for the muscle injected as well as the type of toxin used. The goals of the patients, caregivers, and practitioners were used to help guide the management of these patients. As a result, the practice patterns of Canadian physicians who treat shoulder spasticity are varied, due to numerous patient factors. Future studies are needed to analyze optimal treatment patterns, and the development of algorithms to standardize care.

Physiotherapy Efficiency in Post-stroke Upper Extremity Spasticity: TENS vs. Ultrasound vs. Paraffin.

Post-stroke spasticity is a significant debilitating condition with negative consequences on individual functional independence and quality of life. This study aimed to identify the differences between transcutaneous electrical stimulation (TENS), ultrasound therapy and paraffin procedures on post-stroke upper extremity spasticity and dexterity. Twenty-six patients were enrolled in the study, divided into three therapy groups: TENS (n=9), paraffin (n=10) and ultrasound therapy (n=7). For 10 days, the patients received specific group therapy and conventional physical therapy exercises for upper extremities. Modified Ashworth Scale, Functional Independence Measure, Functional Coefficient, Stroke Specific Quality of Life Scale, Activities of Daily Living score and ABILHAND questionnaire were used to assess the participants before and after therapy. The results of the group comparisons by analysis of variance showed no significant difference between outcomes by the applied treatments. In contrast, one-way analysis of variance suggested significant improvements in patients in all three groups after therapy. Step-wise regression results on functional independence measure and quality-of-life scales suggested that functional range of motion values for elbow and wrist influence individual independence and quality of life. TENS, ultrasound, and paraffin therapy bring equal benefits in the management of post-stroke spasticity.

The Effect of Neuromuscular Electrical Nerve Stimulation in the Management of Post-stroke Spasticity: A Scoping Review.

Stroke is a cerebrovascular disorder characterized by the sudden onset of symptoms and clinical signs caused by either vascular infraction or hemorrhage. One of the main symptoms in the majority of post-stroke patients is spasticity. The main therapeutic options of spasticity in post-stroke patients include pharmacological interventions, rehabilitation techniques, and surgery. This review aims to explore the effectiveness of Neuromuscular Electrical Stimulation (NMES) for post-stroke spastic hemiparetic limb (upper and lower). Thorough research of the PubMed Medline database was performed. Records were limited to clinical studies published between 01/01/2010 and 01/01/2022. The results were screened by the authors in pairs. The search identified 26 records. After screening, nine records met the inclusion-exclusion criteria and were assessed. There were seven studies for spastic upper limbs and two for spastic lower limbs. The approaches investigated the effectiveness of electrical stimulation on post-stroke spastic upper or lower limb. Spasticity was measured through the modified Ashworth scale (MAS) and electromyographic recordings (EMG). In most cases, spasticity was decreased for at least two weekspost-intervention. In conclusion, NMES can be used either solo or in combination with different physical therapy modalities in order to produce optimal results, taking into consideration the specific needs and limitations of each individual patient. Based on the existing literature, as well as the limitations of the included studies, the authors believe that future studies on the subject of NMES in the management of post-stroke spasticity should focus on carefully examining each electrical parameter.

Motor unit distribution and recruitment in spastic and non-spastic bilateral biceps brachii muscles of chronic stroke survivors

Objective. This study aims to characterize the motor units (MUs) distribution and recruitment pattern in the spastic and non-spastic bilateral biceps brachii muscles (BBMs) of chronic stroke survivors. Approach. High-density surface electromyography (HD-sEMG) signals were collected from both spastic and non-spastic BBMs of fourteen chronic stroke subjects during isometric elbow flexion at 10%, 30%, 50% and 100% maximal voluntary contractions (MVCs). By combining HD-sEMG decomposition and bioelectrical source imaging, MU innervation zones (MUIZs) of the decomposed MUs were first localized in the 3D space of spastic and non-spastic BBMs. The MU depth defined as the distance between the localized MUIZ and its normal projection on the skin surface was then normalized to the arm radius of each subject and averaged at given contraction level. The averaged MU depth at different contraction levels on a specific arm side (intra-side) and the bilateral depths under a specific contraction level (inter-side) were compared. Main results. The average depth of decomposed MUs increased with the contraction force and significant differences observed between 10% vs 50% (p < 0.0001), 10% vs 100% (p < 0.0001) and 30% vs 100% MVC (p = 0.0017) on the non-spastic side, indicating that larger MUs with higher recruitment threshold locate in deeper muscle regions. In contrast, no force-related difference in MU depth was observed on the spastic side, suggesting a disruption of orderly recruitment of MUs with increase of force level, or the MU denervation and the subsequent collateral reinnervation secondary to upper motor neuron lesions. Inter-side comparison demonstrated significant MU depth difference at 10% (p= 0.0048) and 100% force effort (p= 0.0026). Significance. This study represents the first effort to non-invasively characterize the MU distribution inside spastic and non-spastic bilateral BBM of chronic stroke patients by combining HD-sEMG recording, EMG signal decomposition and bioelectrical source imaging. The findings of this study advances our understanding regarding the neurophysiology of human muscles and the neuromuscular alterations following stroke. It may also offer important MU depth information for botulinum toxin injection in clinical post-stroke spasticity management.

How Different or Similar Is Management of Post-Stroke Spasticity With Botulinum Toxin When Pain Is Present?

How Different or Similar Is Management of Post-Stroke Spasticity With Botulinum Toxin When Pain Is Present?

What Categories of Goals Are More Impacted by Adjuvant Therapies in Post-Stroke Spasticity Management With Botulinum Toxin Type A? An Analysis of 20 Years of Real-World Data

What Categories of Goals Are More Impacted by Adjuvant Therapies in Post-Stroke Spasticity Management With Botulinum Toxin Type A? An Analysis of 20 Years of Real-World Data

Effects of dry needling and exercise therapy on post-stroke spasticity and motor function– protocol of randomized clinical trial

BackgroundSpasticity is one of the most common problems after the first stroke. Dry needling (DN) has been presented as a new therapeutic approach used by physiotherapists for the management of post-stroke spasticity. This study aimed to determine whether the addition of exercise therapy to the DN results in better outcomes in wrist flexors spasticity, motor neuron excitability, motor function and range of motion (ROM) in patients with chronic stroke. MethodsWe will use a single-blind randomized controlled trial (RCT) in accordance with the CONSORT guidelines. A total of 24 patients with stroke will be included from the University Rehabilitation Clinics. The outcome measures will include Modified Modified Ashworth Scale, Hmax/Mmax ratio, H-reflex latency, Action Research Arm Test, Fugl-Meyer Assessment, and wrist extension active and passive range of motion. Patients in the DN and exercise therapy group will undergo 4 sessions of deep DN in flexor carpi radialis and flexor carpi ulnaris muscles on the affected upper limb and exercise therapy. Participants in the DN group will only receive DN for target muscles. Clinical and neurophysiological tests will be performed at baseline, after four therapy sessions, and at three weeks’ follow-up. DiscussionThis study will provide evidence for additional effects of exercise therapy to DN in comparison to DN alone on wrist flexors spasticity, motor neuron excitability, upper-limb motor function, and ROM in patients with chronic stroke.

The Emergence of Dry Needling in Stroke Rehabilitation

The management of stroke, acute revascularization and rehabilitation techniques have taken a giant leap in the current decade. The presence of neurological deficits, spasticity and pain are the common limiting factors in post-stroke patients. The various rehabilitation measures in stroke are focused on improving the trio. Spasticity, in a post-stroke patient, is disabling and can be managed using oral pharmacological agents, botulinum toxin, intrathecal baclofen. The use of needle therapy, dry needling, which was commonly used in the management of myofascial pain syndromes has emerged useful in the management of spasticity. Further recent evidence has shown it to be useful in the other dimensions of stroke rehabilitation. Dry Needling is a skilled intervention, that is performed by trained personnel using a filiform needle. It can be performed superficially or deep. The speculative mechanisms by which dry needling reduces spasticity include inducing stretch in the muscle and afferent modulation of the sensory information from the muscle. It improves blood flow and oxygenation, reduces pain through central and peripheral mechanisms. (1)&#x0D; The use of dry needling in neurology has evolved from its use in the management of myofascial pain to spasticity in spastic tetra paresis and stroke rehabilitation. In post-stroke patients, dry needling has been used in the management of post-stroke spasticity, balance, post-stroke pain. In the management of spasticity, dry needling using ‘pistoning technique’ in the lower limbs (gastrocnemius, tibialis posterior) and upper limbs (shoulder, elbow and wrist) revealed improved scores in modified modified Ashworth scale (MMAS) that translated to improved gait and range of upper limb motion respectively. The dry needling was performed for 1 minute in each muscle studied. However, the number of sessions varied from a single session to 8-week therapy between studies. In the management of balance, the dry needling of the involved tibialis posterior muscle improved the balance as measured by single-leg stance, balance component of Fugl-Meyer scale and dynamic posturography. The improvement in the above measures is also shown to improve the functional outcome of post-stroke patients in Barthel index, 10-metre walk test, timed up and go test. The dry needling is shown to reduce pain including post-stroke shoulder pain by reducing the pain threshold. The above effects of dry needling were also evident in ultrasound assessment of the intervened gastrocnemius muscle that showed improved muscle length, reduced mean muscle thickness and angle of pennation. (1-3)&#x0D; The dry needling has also been studied in post-stroke rehabilitation as a component of the multimodal approach. The use of dry needling in conjunction with electrical stimulation of the muscle is shown to produce persistent improvement in the tone of the muscle. The adverse events noted following the use of dry needling include post interventional muscle soreness, bleeding, bruise and pain during the intervention. Major side effects such as loss of consciousness are rare and hence dry needling serves as a safe therapeutic option in the rehabilitation of post-stroke patients. (1-3)&#x0D; Hence dry needling is a safe, cost-effective technique that can be used in the management of post-stroke spasticity, balance, pain that translates to improved functional outcomes. However, further evidence is required to establish the efficacy of this promising technique in the management of post-stroke rehabilitation.

Dry needling in stroke

Stroke causes acute neurological deficit which is an important cause of morbidity and mortality. Neurorehabilitation is an important dimension in the management of post-stroke deficits. Spasticity, pain, and neurological deficits are contributors to post-stroke disability. Dry needling (DN) is a technique commonly used in the management of myofascial pain. Recent evidence suggests its efficacy in the management of post-stroke disability. The descriptive review on the use of DN summarises the evidence for the management of post-stroke patients such as spasticity, balance, pain, functional outcome, tremor, and ultrasonographic evidence. The filiform needle is inserted into the target muscle until a local twitch response is obtained. The effects of DN are produced by the local stretch of the spastic muscle and afferent modulation of the reflex arc that decreases the excitability of the alpha motor neuron. The DN reduces muscle spasticity in post-stroke patients. The improved spasticity is translated to better functional outcomes and balance. The procedure is also shown to reduce pain including post-stroke shoulder pain. It is also shown to improve tremors in post-stroke patients. Ultrasonographic evidence of the beneficial effects of DN shows improved measures in the pennate angle and mean muscle thickness. Concurrent use of DN and electrical stimulation improve spasticity, the effect which may be seen for longer periods. DN is emerging as a useful and cost-effective technique in the management of post-stroke patients. The evidence for the use of DN in the management of post-stroke spasticity is high. However, more research is required to assess its efficacy in functional outcomes and other aspects of the stroke.

Early Use of Phenol Neurolysis Likely Reduces the Total Amount of Botulinum Toxin in Management of Post-Stroke Spasticity.

The main objective was to examine practice patterns of phenol neurolysis for post-stroke spasticity management in the early stage. We performed a chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke and received phenol neurolysis within 15 months post-stroke. Out of 2,367 stroke admissions from January 2014 and December 2018, 68 patients met the criteria. 52.9% of these patients received phenol neurolysis within 12 weeks, i.e., early stage. The earliest phenol neurolysis procedure was at 19 days after stroke. On average, patients received first phenol injections at 16.3 weeks after stroke with an average dose of 7.3 ml. Most commonly injected nerves were tibial nerve motor branches (41/68), sciatic nerve motor branches (37/68), lateral pectoral nerve (16/68), medial pectoral nerve (15/68), obturator nerve (15/68) and musculocutaneous nerve (15/68). Among 68 patients, 24 received phenol only; 17 received phenol neurolysis first followed by botulinum toxin (BoNT) injections; 19 received BoNT injections first followed by phenol neurolysis; 8 received both phenol and BoNT injections at the same time. The interval from stroke to first procedure was similar between the Phenol-First group (13.3 weeks) and the BoNT-First group (12.6 weeks). The total amount of BoNT was significantly lower in the Phenol-First group (361.3 units) than in the BoNT-First group (515.8 units) (p = 0.005). The total amount of phenol was not statistically different between the Phenol-First group (5.9 ml) and the BoNT-First group (8.3 ml). The interval between the first procedure and its subsequent procedure was not statistically different between the Phenol-First group (18.3 weeks) and the BoNT-First group (10.7 weeks). These long intervals suggest that the subsequent injection (type and dose) was not planned during the first procedure. The general patterns of target areas were similar between BoNT injections and phenol neurolysis, except that phenol neurolysis rarely targeted the upper extremity distal muscles. No side effects after phenol or BoNT injections in the early stage after stroke were observed in the chart review. In summary, phenol neurolysis was started as early as 19 days after stroke. On average, patients received first phenol about 4 months after stroke with an average of 7.3 ml of phenol. Early use of phenol neurolysis likely decreases the total amount of BoNT for management of post-stroke spasticity without increased side effects.

Real-world analysis of botulinum toxin (BoNT) injections in post-stroke spasticity: Higher doses of BoNT and longer intervals in the early-start group

Our primary objective was to compare early-start vs. late-start Botulinum toxin (BoNT) injections in post-stroke spasticity management. This is an IRB approved retrospective chart review of patients who were admitted for inpatient rehabilitation within 6 months after first-ever stroke between January 2014 and December 2018 and received BoNT injections within 15 months. The total dose and interval between consecutive injections were used as objective outcomes. 2367 stroke admissions were reviewed. 189 patients metinclusion criteria. 68 out of 189 patients received BoNT injections within 12 weeks after stroke (EARLY group). 20 patients in the EARLY group who received at least three cycles were included for analysis. Out of 189 patients, 47 patients were categorized into the Early- and Late-start subgroups each by time from stroke onset to first BoNT injection (1st and 4th quartiles of time distribution) for comparisons. In the EARLY group, the first interval (Mean (M) = 7.6 weeks, standard deviation (SD) = 2.14) was significantly shorter than the second interval (M = 23.7, SD = 10.41) and the third interval (M = 20.0, SD = 11.23; p < 0.05). The dose at the first cycle (M = 492 units, SD = 201.5) was significantly lower than the dose at the third cycle (M = 605, SD = 82.6). In comparison between the Early- and Late-start subgroups, the time to first BoNT injection was 6.4 weeks (range: 4.7–8.6) after stroke for the Early-start subgroup and 49.6 weeks (range: 27.4–62.3) after stroke for the Late-start subgroup. The subsequent intervals after the first injection were significantly longer in the Early-start subgroup (M = 23.1 weeks) than in the Late-start subgroup (M = 14.6 weeks) (p = 0.008). The average total dose of BoNT was significantly higher in the Early-start subgroup (M = 561.9 units, SD = 143.1) than the Late-start subgroup (M = 470.0, SD = 164.8) (p = 0.012). The findings showed that higher doses of BoNT were used in the Early-start group, and often resulted in longer intervals between subsequent injections than in the Late-start group.

The Effects of Extracorporeal Shock Wave Therapy on Spastic Muscle of the Wrist Joint in Stroke Survivors: Evidence From Neuromechanical Analysis.

Background: This study combined neuromechanical modeling analysis, muscle tone measurement from mechanical indentation and electrical impedance myography to assess the neural and peripheral contribution to spasticity post stroke at wrist joint. It also investigated the training effects and explored the underlying mechanism of radial extracorporeal shock wave (rESW) on spasticity.Methods: People with first occurrence of stroke were randomly allocated to rESW intervention or control group. The intervention group received one session of rESW therapy, followed by routine therapy which was the same frequency and intensity as the control group. Outcome measures were: (1) NeuroFlexor method measured neural component (NC), elastic component (EC) and viscosity component (VC), and (2) myotonometer measured muscle tone (F) and stiffness (S), (3) electrical impedance myography measured resistance (R), reactance (X) and phase angle (θ); (4) modified Asworth scale; (5) Fugl Meyer Upper limb scale. All outcome measures were recorded at baseline, immediately post rESW and at 1-week follow-up. The differences between the paretic and non-paretic side were assessed by t-test. The effectiveness of rESW treatment were analyzed by repeated-measures one-way analysis of variance (ANOVA) at different time points.Results: Twenty-seven participants completed the study. NC, EC, and VC of the Neuroflexor method, F and S from myotonometer were all significantly higher on the paretic side than those from the non-paretic side. R, X, and θ from electrical impedance were significantly lower on the paretic side than the non-paretic side. Immediately after rESW intervention, VC, F, and S were significantly reduced, and X was significantly increased. The clinical scores showed improvements immediate post rESW and at 1-week follow-up.Conclusions: The observed changes in upper limb muscle properties adds further support to the theory that both the neural and peripheral components play a role in muscle spasticity. ESW intervention may be more effective in addressing the peripheral component of spasticity in terms of muscle mechanical properties changes. The clinical management of post stroke spasticity should take into consideration of both the neural and non-neural factors in order to identify optimal intervention regime.

The Current State of Knowledge on the Clinical and Methodological Aspects of Extracorporeal Shock Waves Therapy in the Management of Post-Stroke Spasticity—Overview of 20 Years of Experiences

In many patients after stroke, spasticity develops over time, resulting in a decrease in the patient’s independence, pain, worsening mood, and, consequently, lower quality of life. In the last ten years, a rich arsenal of physical agents to reduce muscle tone such as extracorporeal shock therapy (ESWT) wave has come through. The aim of this narrative review article is to present the current state of knowledge on the use of ESWT as a supplement to the comprehensive rehabilitation of people after stroke suffering from spasticity. The PubMed and PEDro databases were searched for papers published in English from January 2000 to December 2020, 22 of which met inclusion criteria for clinical studies related to post-stroke spasticity management with ESWT. A total of 22 studies including 468 post-stroke patients—11 reports with the upper limb (267 patients) and 10 reports within the lower limb (201 patients), as well as one report including both upper and lower limb. We focused our attention on clinical and methodological aspects. Therefore, we performed the assessment of enrolled studies in terms of methodological quality using the PEDro and level of evidence using the National Institute for Health and Clinical Excellence (NICE) guidelines. Furthermore, we indicated implications for clinical practice in using ESWT for post-stroke spasticity management. Moreover, we discussed a suggestion for future research directions. In conclusion, an ESWT effectively reduces muscle tone in people with spastic limb after stroke. Further, ESWT is safe and free of undesirable side effects. The mechanism of action of ESWT on muscles affected by spasticity is still unknown. To date, no standard parameters of ESWT in post-stroke spasticity regarding intensity, frequency, location, and the number of sessions has been established. Further research, meeting the highest standards, is needed to establish uniform muscle stimulation parameters using ESWT.

Early Identification, Intervention and Management of Post-stroke Spasticity: Expert Consensus Recommendations.

Stroke patients with spasticity usually require long-lasting care and interventions but frequently report that outpatient and community treatment is limited, reflecting a significant unmet need in health and social care provision. Rehabilitation and spasticity management services are essential for patient recovery, with improvements in both activity and participation reducing the burden on patients, family and society. Current clinical guidance provides scope for improvements in both post-stroke management and spasticity prevention. However, access to specialist services can be limited and the patient journey does not always match national recommendations. Identification of spasticity and its predictors and lack of subsequent referral to rehabilitation or specialist spasticity services are key issues in the management of post-stroke spasticity. Implementation of a traffic light classification system prioritises patients at an increased risk of spasticity and promotes early and consistent management across the spectrum of primary and secondary care. The proposed system is based on clinical evidence, expert consensus and recent clinical guidelines. It provides simple and straightforward criteria for management, multidisciplinary consultation and referral to specialist spasticity services, with patients allocated by monitoring requirements and a low (green/periodic monitoring), medium (amber/routine referral) or high risk (red/urgent referral) of spasticity.

Does Dry Needling Increase the Efficacy of Botulinum Toxin Injection in the Management of Post-Stroke Spasticity: A Randomized Controlled Study.

The purpose of the current study was to investigate the antispastic efficacy of dry needling in combination with botulinum toxin-A injections. Thirty stroke patients with elbow flexor spasticity were randomised into two groups; the patients treated with botulinum toxin-A injections and exercise into the BTX-A group, and patients treated with botulinum toxin-A injections, exercise, and dry needling in the BTX-A+Dry needling group. Spasticity was evaluated using the modified Ashworth scale and modified Tardieu scale before treatment, immediately after treatment, the third day after treatment, second week after treatment and at the third month after treatment. The upper extremity motor function was evaluated using the Fugl-Meyer upper extremity motor function scale. A statistically significant difference in all parameters was found after treatment in both groups compared to before treatment (p<0.05). In all evaluation parameters immediately after treatment, on the third day after treatment, the second week after treatment and the third month after treatment, a statistically significant difference in favour of the BTX-A+Dry needling group was achieved compared to before treatment (p<0.05). Dry needling combined with botulinum toxin-A injections performed over a total of four sessions with three-day intervals, contribute to the antispastic effect. Also combined therapy is more effective and provides longer-lasting results.