Spasticity In Chronic Stroke Patients Research Articles

Effects of Additional Radial Shock Wave Therapy on Spasticity of Upper Extremity Muscle

Background: Spasticity is one of the most common problems and greatly interferes with the functional capacity of chronic stroke patients. The most commonly used treatments are infrared therapy and stretching exercises, but they have not reduced spasticity effectively. The addition of Radial Shock Wave Therapy (RSWT) was expected to be more effective in reducing spasticity in chronic stroke patients. Aim: The purpose of this study is to prove that the addition of RSWT is more effective reducing spasticity of chronic stroke patients. Material and methods: This study was a simple randomized controlled pre- and post-experimental design. The total sample of 30 chronic spastic stroke patients with the Modified Asworth Scale 2-3 was divided into 2 groups: the study group and the control group. RSWT was provided once a week to the muscle belly of the flexor wist muscle on the ventral aspect of the forearm, the intrinsic muscle of the hand, and flexor digitorum tendon. They were added to infrared therapy and stretching exercises in the upper extremities which are provided three times a week for six weeks consecutively. The level of spasticity was measured by the Tardieu Scale, which measures quality and angle of resistance at the beginning and end of the study. Results: A significantly greater reduction was obtained (p<0.05) from the level of spasticity measured by the Tardieu Scale, both on the quality and angle of resistance, in the study group. Conclusion: The addition of RSWT has been shown to have a greater reduction in spasticity in upper extremity muscle in chronic stroke patients.

Surgical quadriceps lengthening can reduce quadriceps spasticity in chronic stroke patients. A case-control study.

BackgroundMuscle overactivity is one of the positive signs of upper motor neuron lesions. In these patients, the loss of muscle length and extensibility resulting from soft tissue rearrangement has been suggested as a contributing cause of muscle overactivity in response to stretching.ObjectiveTo assess the effects of surgical lengthening of the quadriceps femoris (QF) muscle-tendon unit by aponeurectomy on muscle spasticity.MethodsThis is a case-control study on chronic stroke patients with hemiparesis that have undergone lower limb functional surgery over a 8-year period. CASEs underwent corrective surgery for both the foot and knee deviations, inclusive of a QF aponeurectomy. Controls (CTRLs) underwent corrective surgery for foot deviations only. QF spasticity was assessed with the Modified Tardieu Scale (MTS) before and 1 month after surgery. The Wilcoxon test was used to assess MTS variations over time and the Mann–Whitney test was used to verify the presence of group differences at the 1 month mark.ResultsNinety-three patients were included: 57 cases (30F, 1–34 years from lesion) and 36 controls (12F, 1–35 years from lesion). Before surgery, both CASEs and CTRLs had similar MTS scores (median MTS = 3) and functional characteristics. One month after surgery, QF spasticity was significantly lower in the CASEs compared to CTRLs (p = 0.033) due to a significant reduction of the median MTS score from 3 to 0 in the CASE group (p < 0.001) and no variations in the CTRL group (p = 0.468). About half of the cases attained clinically significant MTS reductions and complete symptom relief even many years from the stroke.ConclusionsFunctional surgery inclusive of QF aponeurectomy can be effective in reducing or suppressing spasticity in chronic stroke patients. This is possibly a result of the reduction in neuromuscular spindle activation due to a decrease in muscle shortening, passive tension, and stiffness.

Effectiveness of a New 3D-Printed Dynamic Hand-Wrist Splint on Hand Motor Function and Spasticity in Chronic Stroke Patients.

Spasticity, a common stroke complication, can result in impairments and limitations in the performance of activities and participation. In this study, we investigated the effectiveness of a new dynamic splint on wrist and finger flexor muscle spasticity in chronic stroke survivors, using a randomized controlled trial. Thirty chronic stroke survivors were recruited and randomly allocated to either an experimental or control group; 25 completed the 6-week intervention program. The participants in the experimental group were asked to wear the dynamic splint at least 6 h/day at home, for the entire intervention. The participants in the control group did not wear any splint. All the participants were evaluated 1 week before, immediately, and after 3 and 6 weeks of splint use, with the modified Ashworth scale and the Fugl−Meyer assessment for upper extremity. User experience was evaluated by a self-reported questionnaire after the 6-week intervention. The timed within-group assessments showed a significant reduction in spasticity and improvements in functional movements in the experimental group. We found differences, in favor of the experimental group, between the groups after the intervention. The splint users indicated a very good satisfaction rating for muscle tone reduction, comfort, and ease of use. Therefore, this new splint can be used for at-home rehabilitation in chronic stroke patients with hemiparesis.

Brainstem BOLD response to visual and acoustic stimuli.

Understanding the fundamental roles of brainstem function resulting in proper motor control is critical to motor-rehabilitation after brain injuries. In particular, vestibular and reticular formation nuclei are thought to be associated with spasticity in chronic stroke patients. We used two kinds of stimuli in 10 healthy subjects to activate these nuclei while collecting high-resolution (1.5-mm) fMRI across the majority of brainstem. Optokinetic stimuli evoked illusory self-motion to activate the vestibular nuclei. Acoustic-startle stimuli were sets of loud tones designed to activate of the reticular formation. We summarized the response represented in a form of activation volume, mean percent signal change, and the phase delay (time lag) following the stimulus. We observed patterns of significant activations in the brainstem but did not find significant differences between the stimulus. We conclude that more sensitive measurement techniques are needed to reliably detect vestibular and reticular formation nuclei responses.

Effects of a 3D-printed orthosis compared to a low-temperature thermoplastic plate orthosis on wrist flexor spasticity in chronic hemiparetic stroke patients: a randomized controlled trial

Objective: The aim of this study was to compare the effects of two kinds of wrist-hand orthosis on wrist flexor spasticity in chronic stroke patients. Design: This is a randomized controlled trial. Setting: The study was conducted in a rehabilitation center. Participants: A total of 40 chronic hemiparetic stroke patients with wrist flexor spasticity were involved in the study. Interventions: Patients were randomly assigned to either an experimental group (conventional rehabilitation therapy + 3D-printed orthosis, 20 patients) or a control group (conventional rehabilitation therapy + low-temperature thermoplastic plate orthosis, 20 patients). The time of wearing orthosis was about 4–8 hours per day for six weeks. Main measures: Primary outcome measure: Modified Ashworth Scale was assessed three times (at baseline, three weeks, and six weeks). Secondary outcome measures: passive range of motion, Fugl-Meyer Assessment score, visual analogue scale score, and the swelling score were assessed twice (at baseline and six weeks). The subjective feeling score was assessed at six weeks. Results: No significant difference was found between the two groups in the change of Modified Ashworth Scale scores at three weeks (15% versus 25%, P = 0.496). At six weeks, the Modified Ashworth Scale scores (65% versus 30%, P = 0.02), passive range of wrist extension (P < 0.001), ulnar deviation (P = 0.028), Fugl-Meyer Assessment scores (P < 0.001), and swelling scores (P < 0.001) showed significant changes between the experimental group and the control group. No significant difference was found between the two groups in the change of visual analogue scale scores (P = 0.637) and the subjective feeling scores (P = 0.243). Conclusion: 3D-printed orthosis showed greater changes than low-temperature thermoplastic plate orthosis in reducing spasticity and swelling, improving motor function of the wrist and passive range of wrist extension for stroke patients.

The Effect of Lower Extremity Strengthening Exercise Using Sliding Stander on Balance and Spasticity in Chronic Stroke: A Randomized Clinical Trial

Purpose: Generally, patients with stroke present with decreased balance and increased spasticity following weakness of the paralyzed muscles. Muscle weakness caused by stroke has two causes. This is caused by a decrease in motor output and an adaptive muscle change, resulting in muscle weakness and muscle paralysis. The purpose of this study was to investigate the effect of strengthening ex ercise on balance and spasticity in chronic stroke patients and to suggest the basis of clinical treatment. Methods: Twenty subjects were divided into two groups: a lower-extremity strengthening group (experimental group) and a general physical therapy group (control group). The sliding stander equipment was used for the experimental group and a regimen of warm-up exercise, the main exercise routine, and cool-down exercise were used for the muscle strengthening exercise program. Balance and spas ticity were measured before and after the training period. Balance ability was measured by the Berg balance scale, the Timed up and Go test and the weight distribution of the paralyzed muscles by the Spacebalance 3D. Spasticity was measured by the Biodex system. Results: After the training periods, the experimental group showed a significant improvement in BBS, weight distribution of the para lyzed muscles, and decreased spasticity when compared to the control group (p<0.05). Conclusion: This study supported the hypothesis that lower-extremity strengthening exercise improves the balance and decreases the spasticity of stroke patients. If it is combined with conventional neurologic physiotherapy, it would be effective rehabilitation for stroke patients.

Effectiveness of shock wave therapy on triceps surae spasticity in chronic stroke patients

Shock wave therapy (SWT) has shown some effectiveness in the spasticity treatment. However, few randomized controlled trials remained available, particularly in long-term spasticity, and the effect of a single session of treatment has poorly been assessed. Sixteen adults with a long-term stroke (4.3 ± 6 years post-stroke) and presenting a spasticity of the triceps surae were included. Patients were submitted to two sessions of shock wave therapy: one session (real-SWT) of 6000 real shocks (8 Hz; 1.6 bar) applied on the triceps surae, and one session (sham-SWT) of 6000 sham shocks. Both sessions were separated by a one week interval, and allocated in a random order. Patients were assessed immediately before and after each session of SWT. Assessment was carried out by a blind assessor, and included the Modified Ashworth Scale (MAS) and the Tardieu scale (TS) of the triceps surae (assessed with knee flexed and knee extended), as well as a ten-meter walking test (10MWT). The MAS score (knee flexed) and the TS score (knee extended) improved significantly after real-SWT, but not after sham-SWT ( P = 0.007 and 0.01, respectively). The median improvement was 0.5[0;1] on the MAS and 1[0;2] on TS. However, the 10MWT remained unchanged. A single session of shock wave therapy can be effective to improve spasticity, but not walking ability, in long-term spasticity. Larger studies are needed to confirm this hypothesis.

The effects of focal muscle vibration to reduce calf muscle spasticity in chronic stroke patients: Preliminary study

Recently, several studies have investigated the anti spastic effect of focal muscle vibration in patients with stroke. It was also reported than vibratory stimulation on hemiplegic lower limb increased gait speed in stroke patients.

The Effect of Radial Extracorporeal Shock Wave Stimulation on Upper Limb Spasticity in Chronic Stroke Patients: A Single–Blind, Randomized, Placebo-Controlled Study

The main purpose of this study was to determine the clinical, electrophysiological and thermal effects of radial extracorporeal shock wave (rESW) stimulation on upper limb muscles affected by spasticity in patients with chronic stroke. Patients included in the study were randomly assigned into the following two groups: 30 patients stimulated with active rESW (A); and 30 patients stimulated with placebo rESW (B). All patients were analyzed using the Modified Ashworth Scale (MAS) to test the spasticity levels of the elbow (E), radio carpal (RC) and fingers (FF) joints; surface electromyography (sEMG) was performed for the resting bioelectrical activity registration of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) muscles; and infrared thermal imaging (IRT) was used to assess the temperature distributions of the carpal flexor muscles (CFM). All assessments were performed at baseline (t0), immediately after rESW (t1) as well as 1 and 24 h following its finalization (t2 and t3). Patients treated with active rESW showed a statistically significant reduction in the MAS score for the RC joint at t1 and for the FF joints at t1, t2 and t3 (p < 0.05). A significant decrease in sEMG activity was observed in the FCR and FCU muscles at t1, t2 and t3 (p < 0.05); significant increases in the mean and maximum values of the IRT detection was observed using inter-group comparisons in t2 and t3 (p < 0.05). No significant alterations were observed in patients after placebo rESW stimulation (p > 0.05). Applications of rESW demonstrating positive effects at reducing the level of spastic hypertonia of the upper limb muscles in patients with chronic stroke. ESW treatments should be considered as a potential anti-spastic effect to regulate vasculature.

The relationships of motor-evoked potentials to hand dexterity, motor function, and spasticity in chronic stroke patients: a transcranial magnetic stimulation study.

The standardization of patient evaluation and monitoring methods has a special importance in evaluating the effectiveness of therapeutic methods using drugs or rehabilitative techniques in stroke rehabilitation. The aim of this study was to investigate the relationships between clinical instruments and transcranial magnetic stimulation (TMS)-evoked neurophysiological parameters in stroke patients. This study included 22 chronic post-stroke patients who were clinically assessed using the Motricity Index (MI), finger-tapping test (FTT), Motor Activity Log (MAL) 28, Brunnstrom motor staging and Ashworth Scale (ASH). Motor-evoked potential (MEP) latency and amplitude, resting motor threshold (rMT) and central motor conduction time (CMCT) were measured with TMS. Shorter MEP-latency, shorter CMCT, higher motor-evoked potential amplitude, and diminished rMT exhibited significant correlations with clinical measures evaluating motor stage, dexterity, and daily life functionality. rMT exhibited a negative correlation with hand and lower extremity Brunnstrom stages (r=-0.64, r=-0.51, respectively), MI score (r=-0.48), FTT score (r=-0.69), and also with amount of use scale and quality of movement scale of MAL 28 scores (r=-0.61, r=-0.62, respectively). Higher MEP amplitude and diminished rMT showed positive correlations with reduced ASH score (r=-0.65, r=0.44, respectively). The TMS-evoked neurophysiologic parameters including MEP latency, amplitude, rMT and CMCT generally have positive correlation with clinical measures which evaluate motor stage, dexterity and daily life functionality. Additionally, spasticity has also remarkable relationships with MEP amplitude and rMT. These results suggest that TMS-evoked neurophysiological parameters were useful measures for monitoring post-stroke patients.

Selection of acupoints for managing upper-extremity spasticity in chronic stroke patients.

BackgroundThis study investigated the clinical efficacy of electroacupuncture (EA) in inhibiting upper-extremity spasticity in chronic stroke patients, and also in mapping a unique preliminary acupoint-selection protocol.MethodsFifteen patients were divided into two groups: patients in the control group (n=6) received minimal acupuncture (MA), and those in the experimental group (n=9) received EA. Four acupoints, which include Neiguan (PC6), Shaohai (HT3), Zeqian (Ex-UE, A32), and Shounizhu (EX-UE), were treated near the motor points of the muscles for elbow flexion, forearm pronation, and finger flexion. Both groups were treated for twelve sessions, 20 minutes per session, for 6 weeks (two sessions per week). The outcome measures in this study included angle of muscle reaction (R1), passive range of motion (R2), and dynamic component (R2–R1).ResultsIn the experimental group, the R2–R1 of the elbow joint was significantly decreased at 1 (P=0.0079), 3 (P=0.0013), and 6 weeks (P=0.0149) after treatment compared with pretreatment levels (P<0.05). The between-group difference in the R2–R1 of the elbow joint after the 6-week treatment was statistically significant.ConclusionCombining the 6-week EA and standard rehabilitation treatment reduced the spasticity of the elbow for chronic stroke survivors. However, no significant effect was observed in the spasticity of the wrist joints. The choice of acupoints and the frequency of EA have to be taken into account to achieve a positive treatment effect. The correlation between acupoints and motor points provides a model of acupoint selection to improve spasticity.

Relationship between neuromuscular fatigue and spasticity in chronic stroke patients: A pilot study

IntroductionThe aim of this study was to assess the effects of neuromuscular fatigue on stretch reflex-related torque and electromyographic activity of spastic knee extensor muscles in hemiplegic patients. The second aim was to characterize the time course of quadriceps muscle fatigue during repetitive concentric contractions. MethodsEighteen patients performed passive, isometric and concentric isokinetic evaluations before and after a fatigue protocol using an isokinetic dynamometer. Voluntary strength and spasticity were evaluated following the simultaneous recording of torque and electromyographic activity of rectus femoris (RF), vastus lateralis (VL) and biceps femoris (BF). ResultsIsometric knee extension torque and the root mean square (RMS) value of VL decreased in the fatigued state. During the fatigue protocol, the normalized peak torque decreased whereas the RMS of RF and BF increased between the first five and last five contractions. There was a linear decrease in the neuromuscular efficiency-repetitions relationships for RF and VL. The peak resistive torque and the normalized RMS of RF and VL during passive stretching movements were not modified by the fatigue protocol for any stretch velocity. DiscussionThis study showed that localized quadriceps muscle fatigue caused a decrease in voluntary strength which did not modify spasticity intensity. Changes in the distribution of muscle fiber type, with a greater number of slow fibers on the paretic side, may explain why the stretch reflex was not affected by fatigue.

Effects of a single session of whole body vibration on ankle plantarflexion spasticity and gait performance in patients with chronic stroke: a randomized controlled trial

Objective: To investigate the effects of a single session of whole body vibration training on ankle plantarflexion spasticity and gait performance in chronic stroke patients. Design: Randomized controlled trial. Setting: Rehabilitation unit in university hospital. Participants: Thirty subjects with chronic stroke were randomized into either a control group (n = 15) or a group receiving a single session of whole body vibration (n = 15). Intervention: The intervention group was actually treated with whole body vibration while the control group was treated with placebo treatment. Main measures: The spastic changes were measured clinically and neurophysiologically. Subjective evaluation of ankle spasticity was performed via a visual analogue scale. Gait performances were evaluated by the timed up and go test, 10-meter walk test and cadence. A forceplate was used for measuring foot pressure. Results: The changes between whole body vibration and control groups were significantly different in Modified Ashworth Scale (1.33, 95% confidence interval (CI) = 1.06~1.60). The Hmax/Mmax ratio (0.14, 95% CI = 0.01~0.26) and visual analogue scale (1.87, 95% CI = 1.15~2.58) were significantly decreased. Whole body vibration could significantly improve gait velocity, timed up and go test (6.03, 95% CI = 3.17~8.89) and 10-meter walk test (1.99, 95% CI = 0.11~3.87). The uneven body weight posture on bilateral feet was also improved after vibration. Conclusion: These results suggest that a single session of whole body vibration training can reduce ankle plantarflexion spasticity in chronic stroke patients, thereby potentially increasing ambulatory capacity.

The effect of a stretching device on hand spasticity in chronic hemiparetic stroke patients

We attempted to evaluate the effect of a stretching device for treatment of hand spasticity in chronic stroke patients. We recruited 21 chronic hemiplegic stroke patients with severe finger flexor spasticity and randomly assigned them to the intervention group (10 patients) and control group (11 patients). The stretching device consisted of a resting hand splint, finger stretcher, and frame. The stretching state was maintained for 30 seconds and relaxed for the next 30 seconds. This stretching and relaxation were repeated for 20 minutes (one session). The stretching program was practiced 2 sessions/day and 6 days/week for 3 weeks for the patients of the intervention group. The effect of this stretching device was assessed using the modified Ashworth scale (MAS) score of finger flexor muscles. Patients in both groups were assessed six times within an interval of one week and patients in the intervention group were assessed two times before starting the stretching program. The two-way repeated measures analysis of variance (ANOVA) test for evaluation of the effect of intervention across all time-points between the two groups showed a significant interaction between time and effect of intervention (P < 0.001). Within the intervention group, the average of mean MAS score at Pre-1 and Pre-2 were 2.83 and 2.93, respectively (the difference between Pre-1 and Pre-2 was not significant (P> 0.05)), and this improved significantly to 1.97 at Inter-1, 1.55 at Inter-2, 1.20 at Inter-3, and 1.97 at Post-1 (P < 0.001) using the one-way repeated measures ANOVA test for evaluation of the effect of intervention across all time-points. We found that our stretching device was effective in relieving hand spasticity in chronic stroke patients.

Efectos de la toxina botulínica tipo A y electroestimulación en la espasticidad flexora distal de la extremidad superior en el ictus. Ensayo clínico aleatorizado

Objective To evaluate the efficacy of the Neuromuscular Electrical Stimulation (NMES) associated to Botulinum Toxin (TB) type A in motor function, functional capacity and spasticity in chronic post-stroke upper limb (UL) spasticity. Patients and methods A randomized controlled clinical trial was performed in 25 ictus patients with more than 6 months evolution. After infiltration of 200 units of TB in the flexor muscle of the finger and wrist muscles, the patients were assigned to two groups: NMES in extensor muscles (group 1) and sham-stimulation (group 2). Patients were assessed at weeks 4/16 post-injection by standard motor function scales (Fugl-Meyer Motor Assessment (FMA), Medical Research Council Scale (MRC), Motricity Index for Motor Impairment after stroke and dynamometry), UL functional capacity (Chedoke Arm and Hand Activity Inventory (CAHAI), Box and Block Test (BBT) and muscular tone (Modified Ashworth Scale (MAS)). Results At week 4, significant improvement was observed in FMA 2.4 (SD 4.1) in UL component, MRC 0.2 (SD 0.4), CAHAI 4.2 and BBT 1.5 (SD 3.3), as well as a reduction in MAS 1.0 (SD 0.9) in the wrist and 1.2 (SD 1.4) in the fingers. At month 4, this effect was maintained in motor function but not in spasticity. No significant differences were observed in UL motor function, functional capacity between the groups. Conclusions TB type A injection in UL distal flexor spasticity enhances motor function, functional capacity and spasticity in chronic stroke patients. Adding a program of NMES for the extensor wrist/fingers muscles does not provide any additional benefits.

Effect of Shock Wave Therapy on Upper Limb Spasticity in Chronic Stroke

Objective: To investigate the effect and optimal therapeutic frequency of extracorporeal shock wave therapy (ESWT) on upper limb spasticity in chronic stroke patients. Method: Total 16 patients with chronic stroke were evaluated. Patients were divided into 2 groups, one group applied with 4 Hz stimulation, and the other group applied with 8 Hz stimulation. All patients were applied with sham stimulation (0 mj/cm) at the initial time and with active stimulation (0.030 mj/cm) 4 weeks later. Target muscles were dorsal interossei and flexor digitorum profundus. The primary outcome was the finger flexor spasticity using the modified Ashworth scale (MAS), which was serially measured before, after 1 week and after 4 week respectively. Results: Before the study, the MAS of 4 Hz group was 3.90±0.87 and 8 Hz group was 3.89±0.93, which showed no significant difference. After 1 week of active stimulation, the MAS of 4 Hz group (2.90±0.81) was significantly smaller than the MAS of 8 Hz group (3.33±0.88). Treatment effects had been continued to 4 weeks. There were no complications associated with ESWT. Conclusion: ESWT could be used to reduce spasticity of the upper limb muscles in chronic stroke patients. (Brain & NeuroRehabilitation 2010; 3: 94-98)

Vibration improves motor functions and prolongs the cortical silent period in spastic hemiparesis

Introduction: Muscle vibration is known to enhance motor cortical excitability of the vibrated muscle and may inhibit the excitability of non-vibrated antagonistic muscles. In this study, we explored the effects of vibration on spasticity in chronic stroke patients by investigating motor abilities and the cortical silent period (CSP) evoked by Transcranial Magnetic Stimulation (TMS). Spasticity is characterized by an increased tension in flexor muscles and a dysbalance between flexors and extensors, the latter being much weaker. We hypothesized that vibration of forearm extensor muscles could reduce spasticity in forearm flexors and thus transiently improve motor functions.