Upper-limb Spasticity Research Articles

Effects of High-Intensity Electromagnetic Stimulation on Reducing Upper Limb Spasticity in Post-Stroke Patients

Super Inductive System (SIS) stimulation of spastic limbs by tissue-induced electromagnetic field may have the effect of reducing spasticity and improving functionality in patients with post-stroke spasticity. The aim of the study was to evaluate two different protocols for the application of SIS on upper limb spasticity after stroke. We included 60 patients with post-stroke upper limb spasticity, who were randomized into two groups: the study group, with a 9 min application protocol (1 min for agonist muscles, 8 min for antagonistic muscles); and the control group, with an 8 min protocol applied only to the antagonistic muscles. The duration of therapy was 10 days, and the results were assessed using the Modified Ashworth Scale (MAS) and the Barthel Index. Both the MAS and the Barthel Index improved significantly after 10 days of treatment (p < 0.001), but 30 days after the completion of therapy, there was an attenuation of the effects in both study groups. The study group had a significantly higher percentage of patients with improved MAS after 10 days (p = 0.004) and within 30 days (p < 0.001) than the control group. An SIS protocol applied on both agonist and antagonist muscles has a more pronounced and longer lasting spasticity-reducing and improved functionality effect than its application on only antagonistic muscles.

The Effect of Robot-Mediated Virtual Reality Gaming on Upper Limb Spasticity Poststroke: A Randomized-Controlled Trial.

Objective: Stroke is a common reason for motor disability and is often associated with spasticity and poor motor function of the upper limbs involved. Spasticity management is important to accelerate motor recovery. The objective of this study was to investigate the effects of training with robot-mediated virtual reality gaming on upper limb spasticity and motor functions in individuals with chronic stroke. Materials and Methods: A total of 40 Saudi individuals with chronic stroke were involved in this study. Participants were randomly assigned to two groups. The experimental group received conventional physiotherapy and training with robot-mediated virtual reality gaming, and the control group received only conventional physiotherapy. Outcomes were measured by the Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), WMFT-Time, Modified Ashworth Scale (MAS), Active Range of Motion (AROM) of multiple joints of the upper limb, and Handgrip Strength (HGS). The scores of all the outcome measures were recorded at baseline and after the completion of the treatment. Results: Individuals with stroke in the experimental group had a better improvement in most measured variables (AROM of shoulder abduction, elbow supination and wrist extension, WMFT-Time, HGS, ARAT, WMFT, and MAS) compared with the control group after the completion of the treatment. Both groups showed significant improvement in all the measured variables after completion of the treatment, except in MAS for wrist flexors in the control group. Conclusion: Training with robot-mediated virtual reality gaming was effective in modulating spasticity and improving the motor functions of the affected upper limbs in individuals with chronic stroke. This study was registered in ClinicalTrial.gov (NCT05069480).

Effectiveness of surge faradic stimulation and proprioceptive neuromuscular facilitation for rehabilitation of hemiplegic hand in hemiplegic cerebral palsy: a case report

Hemiplegic cerebral palsy presents with unilateral impairment of upper and lower limbs, resulting in spasticity and impaired hand function in daily activities. A 4-year-old patient presented with right upper limb spasticity with difficulty in hand function. There are various physical therapy approaches like passive stretching, task-oriented approach, etc. used in cerebral palsy but have not shown satisfactory results. Current study incorporates proprioceptive neuromuscular facilitation-irradiation along with surge faradic therapy, a combination of physical treatment that works on muscle spasticity and strength. No study has been studied for this combination of therapies for the reduction of spasticity cerebral palsy patients. Hence, this study aims at the effectiveness of combined surge faradic stimulation and PNF irradiation on hand functions in hemiplegic cerebral palsy patient. Outcome measures used in study are TCMS to assess trunk control, MAS to assess spasticity and QUEST to assess hand function skills before and after physiotherapeutic intervention. Present study concluded that surge faradic stimulation and PNF irradiation given for wrist extensors has improved hand function skills, decreased spasticity and improved trunk control in hemiplegic cerebral palsy.

Correlação entre espasticidade do membro superior e movimentação da mão no pós-AVC

ABSTRACT Hemiparesis and spasticity are common consequences in stroke patients, hampering the movement in the affected side. Our study aimed to correlate upper limb spasticity and the ability to move the hand in these patients. This is a quantitative cross-sectional study with an ex post facto correlational design. We evaluated patients undergoing follow-up at the Neurovascular Outpatient Clinic at the Hospital de Clínicas de Porto Alegre. An evaluation form was filled out with sample data and the upper limb spasticity was evaluated using the Modified Ashworth Scale and the active hand movement using the Hand Movement Scale. Correlation of variables were verified using Kendall’s rank correlation coefficient. A significance level of 5% (p≤0.05) was adopted. In total, we evaluated 47 subjects of all genders, with a mean age of 64.5 (±13) years and a mean stroke time of 2.7 (±1.8) months. The Hand movement Scale mode was 6 points, and 74.4% of patients were not spastic. Hand movement showed a significant negative correlation with the spastic muscles evaluated. There was a moderate negative correlation with the pectoral muscles (r=−0.383; p=0.007), elbow flexors (r=−0.339; p=0.016) and pronators (r=−0.460; p=0.001) and high negative correlation with wrist flexors (r=−0.588; p<0.001) and finger flexors (r=−0.692; p<.001). The greater the degree of spasticity of the upper limb, the smaller the hand movement capacity in stroke patients.

Real Life Experience with Individualized Doses of Incobotulinumtoxina in Patients with Severe Spasticity Due to Acquired Brain Injury

The objective of the present study was to evaluate the effectiveness and tolerability of incobotulinumtoxinA, at doses according to individual needs, in 10 patients with acquired brain injury and severe upper and lower limb spasticity. Patients received a multipattern periodic treatment with ultrasound-guided injections of incobotulinumtoxinA at doses of 800-900 U in the upper and lower limbs. The mean number of injection cycles per patient was 4.2. The 0-10 visual analogue scale for pain score decreased significantly from pre-injection (mean: 4.7) to four-week post-injection (mean: 0.7). Similarly, the mean Ashworth Scale score (muscular tone assessment) at four-week post-injection (mean: 1.4) was significantly lower than at injection (mean: 2.5). Except for two patients in one pattern, all cases showed an improvement in passive range of motion assessments using goniometry. All patients reported maximum satisfaction with the treatment, all reporting “much improved” after the treatment. No treatment-related adverse effects were observed during the study. Individualized doses of incobotulinumtoxinA are effective and well-tolerated for this type of patients and allow better management of their severe spasticity. Therefore, individualization of doses should be taken into account for optimizing clinical outcomes and improving the patients’ treatment satisfaction.

Design of a Wearable Vibrotactile Stimulation Device for Individuals With Upper-Limb Hemiparesis and Spasticity.

Vibratory stimulation may improve post-stroke symptoms such as spasticity; however, current studies are limited by the large, clinic-based apparatus used to apply this stimulation. A wearable device could provide vibratory stimulation in a mobile form, enabling further study of this technique. An initial device, the vibrotactile stimulation (VTS) Glove, was deployed in an eight-week clinical study in which sixteen individuals with stroke used the device for several hours daily. Participants reported wearing the glove during activities such as church, social events, and dining out. However, 69% of participants struggled to extend or insert their fingers to don the device. In a follow-up study, eight individuals with stroke evaluated new VTS device prototypes in a three-round iterative design study with the aims of creating the next generation of VTS devices and understanding features that influence interaction with a wearable device by individuals with impaired upper-limb function. Interviews and interaction tasks were used to define actionable design revisions between each round of evaluation. Our analysis identified six new themes from participants regarding device designs: hand supination is challenging, separate finger attachments inhibit fit and use, fingers may be flexed or open, fabric coverage impacts comfort, a reduced concern for social comfort, and the affected hand is infrequently used. Straps that wrap around the arm and fixtures on the anterior arm were other challenging features. We discuss potential accommodations for these challenges, as well as social comfort. New VTS device designs are presented and were donned in an average time of 48 seconds.

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 Interpretation of Working Volume and Weight Support in Upper Limb Robotic Neurorehabilitation after Stroke

In the past two decades, many studies reported the efficacy of upper limb robotic rehabilitation in patients after stroke, also in its chronic phase. Among the possible advantages of robotic therapy over conventional therapy are the objective measurements of kinematic and kinetic parameters during therapy, such as the spatial volume covered by the patient’s upper limb and the weight support provided by the robot. However, the clinical meaning and the usability of this information is still questioned. Forty patients with chronic stroke were enrolled in this study and assessed at the beginning of upper limb robotic therapy (Armeo® Power) and after two weeks (ten sessions) of therapy by recording the working volume and weight support provided by the robot and by administering six clinical scales to assess upper limb mobility, strength, spasticity, pain, neurological deficits, and independency. At baseline, the working volume significantly correlated with spasticity, whereas weight support significantly correlated with upper limb strength, pain, spasticity, and neurological deficits. After two weeks of robotic rehabilitation, all the clinical scores as well as the two parameters improved. However, the percentage changes in the working volume and weight support did not significantly correlate with any of the changes in clinical scores. These results suggest caution in using the robotic parameters as outcome measures because they could follow the general improvement of the patient, but complex relationships with clinical features are possible. Robotic parameters should be analyzed in combination with the clinical scores or other objective measures because they may be informative about therapy progression, and there is a need to combine their clinical, neuroscientific, and biomechanical results to avoid misleading interpretations.

Comparative Study of Botulinum Toxin ‘A’ on Upper and Lower Limb Spasticity: A Clinical Aspect

Comparative Study of Botulinum Toxin ‘A’ on Upper and Lower Limb Spasticity: A Clinical Aspect

Pain Reduction in Adults with Limb Spasticity Following Treatment with IncobotulinumtoxinA: A Pooled Analysis.

Some studies have shown that incobotulinumtoxinA reduces spasticity-associated pain, but further evidence is needed. This exploratory analysis pooled pain-relief data from six Phase 2 or 3 studies of incobotulinumtoxinA (four placebo-controlled studies) for treating upper limb spasticity in adults. Spasticity-associated pain was assessed at baseline and 4 weeks post incobotulinumtoxinA injection using the disability assessment scale (DAS) for pain. Only data for patients with pain at baseline were analysed. Overall, 544 (incobotulinumtoxinA, N = 415; placebo, N = 129) of 937 patients (58.1%) experienced pain at baseline. At Week 4, a significantly greater proportion of incobotulinumtoxinA- (52.1%) than placebo-treated patients (28.7%; Chi-square p < 0.0001) showed a response (≥1-point improvement in DAS pain score). In logistic regression analysis, incobotulinumtoxinA-treated patients were 2.6 times more likely to achieve this endpoint than placebo-treated patients. A significant difference between incobotulinumtoxinA and placebo was observed regardless of baseline pain severity. Additionally, 27.1% of incobotulinumtoxinA- versus 12.4% of placebo-treated patients reported complete pain relief at Week 4 (p = 0.0006). Pain relief increased with multiple injection cycles. To achieve patient-centred care, pain relief may be considered a treatment goal in adults with spasticity-associated pain regardless of pain severity. This study contributes to understanding the benefits of incobotulinumtoxinA in treating limb spasticity-associated pain.

A consensus statement on the use of botulinum toxin in pediatric patients.

Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.

Electrocupuncture combined rehabilitation therapy for upper limb spasticity after stroke: A protocol for systematic review and meta-analysis.

Background:The purpose of this study was to evaluate the effectiveness and safety of electroacupuncture combined with rehabilitation in the treatment of spasticity after stroke.Methods:To collect relevant literature, we will research following databases: Medicine, PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan-Fang Database, Chongqing VIP Chinese Science and Technology Periodicals Database and China Biomedical Database; the time is from its creation to May 2021, and the language is limited to Chinese and English. In addition, we will retrieve other literature resources, including the Chinese Clinical Trial Register and conference papers. Two reviewers will independently complete the literature screen and data extraction, and quality assessment of the included studies will be independently completed by two other researchers. The primary outcomes included the Modified Ashworth scale (MAS) and the simplified Fugl-Meyer Assessment scale (SFMA). The Modified Barthel Index (MBI), the China Stroke Scale (CSS), and adverse reactions as secondary outcomes were assessed. RevMan V.5.4.1 software will be used for meta-analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) will be used to assess the quality of evidence.Results:This systematic review will provide a high-quality synthesis to evaluate the efficacy and safety of electroacupuncture combined with rehabilitation therapy in the treatment of upper limb spasticity after stroke, providing a reference for the safe and effective treatment of upper limb spasm after stroke.Conclusion:This study provides evidence that electroacupuncture combined with rehabilitation therapy is effective.Ethics and dissemination:The protocol of the systematic review does not require ethical approval because it does not involve humans. This article will be published in peer-reviewed journals and presented at relevant conferences.Systematic review registration:INPLASY202160005.

Treatment of upper limb spasticity with inhibitory repetitive transcranial magnetic stimulation: A randomized placebo-controlled trial.

Upper limb dysfunction is a frequent complication after stroke impairing outcome. Inhibitory repetitive transcranial magnetic stimulation (rTMS) applied over the contralesional hemisphere is supposed to enhance the positive effects of conventional rehabilitative treatment. This double-blind randomized placebo-controlled trial investigated whether inhibitory rTMS as add-on to standard therapy improves upper limb spasticity. Twenty-eight patients (aged 44 to 80 years) with unilateral stroke in the middle cerebral artery territory were analyzed. Participants were randomly assigned to inhibitory, low-frequency (LF-) rTMS (n = 14) or sham-rTMS (n = 14). The primary outcome measure was the spasticity grade, which was assessed with the Modified Ashworth Scale (MAS). In addition, the Fugl-Meyer-Assessment (FMA) for the upper extremity (UE) and a resting-state fMRI were performed to measure motor functions and the sensorimotor network, respectively. The MAS score was reduced in the LF-rTMS group only, whereas the FMA score improved in both groups over time. Regarding the fMRI data, both groups activated typical regions of the sensorimotor network. In the LF-rTMS group, however, connectivity to the left angular gyrus increased after treatment. Changes in functional connectivity in patients receiving inhibitory rTMS over the contralesional motor cortex suggest that processes of neuronal plasticity are stimulated.

The spasticity-related quality of life 6-dimensions instrument in upper-limb spasticity: Part I Development and responsiveness.

ObjectiveTo describe the development of the Spasticity-related Quality of Life 6-Dimensions instrument (SQoL-6D) and its sensitivity to clinical change (responsiveness).DesignMulticentre, prospective, longitudinal cohort study at 8 UK sites (NCT03442660).PatientsAdults (n = 104) undergoing focal treatment of upper limb spasticity.MethodsNo condition-specific health-related quality of life tool is available for upper-limb spasticity of any aetiology. The SQoL-6D was developed to fulfil this need, designed to complement the Upper Limb Spasticity Index (which incorporates the Goal Attainment Scaling evaluation of upper limb spasticity [GASeous] tool) with targeted standardised measures. The 6 dimensions of the SQoL-6D (score range 0–4) map onto common treatment goal areas identified in upper-limb spasticity studies. A Total score (0–100) provides overall spasticity-related health status. To assess responsiveness, the SQoL-6D, Global Assessment of Benefit scale and ”GASeous” were administered at enrolment and 8 weeks.ResultsSignificant differences in mean SQoL-6D Total score change and effect sizes across patients rating ”some benefit” (0.51) and ”great benefit” (0.88) supported responsiveness.ConclusionThe SQoL-6D is a promising new measure of health status in upper limb spasticity, that enables systematic assessment of the impact of this condition in relation to patients’ priority treatment goals. A psychometric evaluation of SQoL-6D is presented separately.LAY ABSTRACTUpper-limb spasticity is a condition in which muscles become ”tight”, restricting use of the arm and hand. Questionnaires have been developed to assess a person’s quality of life, but are not specifically designed to assess the impact of spasticity on a person. The Spasticity-related Quality of Life 6-Dimensions instrument (SQoL-6D) was created to address this deficiency. The development of the SQoL-6D is described here, along with analysis of its responsiveness to ensure that the SQoL-6D detects changes in spasticity symptoms following treatment (as reported by patients using other questionnaires). These analyses showed that the SQoL-6D captured changes in the burden of spasticity for people with this problem. Other technical psychometric properties of the SQoL-6D are reported in the companion paper available in this issue.

The spasticity-related quality of life 6-dimensions instrument in upper-limb spasticity: Part II A first psychometric evaluation.

ObjectivePsychometric evaluation of the Spasticity- related Quality of Life 6-Dimensions instrument (SQoL-6D).DesignA clinimetric evaluation conducted in a multicentre, prospective, longitudinal cohort study at 8 UK sites.PatientsAdult patients (n = 104) undergoing focal treatment of upper-limb spasticity.MethodsThe SQoL-6D was administered in the clinic at enrolment and at 8 weeks, then 1–4 days later at home to assess test-retest reliability.ResultsThe SQoL-6D demonstrated adequate construct validity and unidimensionality of the scale, allowing the calculation of a Total score. Cronbach’s alpha (0.74) supported the internal consistency reliability, while the intraclass correlation coefficient supported test-retest reliability (0.82). Correlation coefficients with established instruments supported convergent validity, while significant differences between known-groups (of differing clinical severity) in SQoL-6D Total score confirmed its sensitivity to both cross-sectional and longitudinal differences.ConclusionThe SQoL-6D is a promising new measure to assess health status for patients with upper-limb spasticity of any aetiology. Further investigation and exploration of the allocation of weights to convert the SQoL-6D to a health-related quality of life utility index, are required.LAY ABSTRACTIn upper-limb spasticity, the use of the arm and hand become restricted due to “tight” muscles. Although questionnaires to assess a person’s quality of life have been developed, they do not specifically assess the impact of upper-limb spasticity. To address this deficiency, the Spasticity-related Quality of Life 6-Dimensions (SQoL-6D) questionnaire was developed (see also the companion “development” paper available in this issue). To test that the SQoL-6D works as expected, it was completed by 104 people living with spasticity and compared with other questionnaires they completed. The results show that the SQoL-6D questions are relevant to people with spasticity. The answers were reliable when the SQoL-6D was repeated, and differences in the burden of spasticity between people grouped by the severity of their condition were captured accurately. The SQoL-6D is a promising new measure to assess aspects of quality of life in people living with spasticity.

Effectiveness of Self-Action Observation Therapy as a Novel Method on Paretic Upper Limb and Cortical Excitability Post-Stroke: A Single-Subject Study

Background: Action Observation Therapy (AOT) is a top-down approach that has been recently introduced in the rehabilitation of neurological disorders mainly after stroke. The main goal of this study was to investigate the effects and feasibility of a new technique in AOT procedure (called self-AOT) following periods of no treatment and routine AOT intervention on upper limb motor function, occupational performance and neurophysiological changes in a stroke patient. Methods: A single-subject A-B-A-C design was used and a 58-year-old woman with a 3-year history of left hemiplegia poststroke participated in this study. In the baseline (A1, A2) phases, the patient received no treatment. In the first intervention (B phase), she received a 4-week AOT, and in the second intervention (C phase), a 4 week of Self-AOT was practiced. In all phases, upper limb motor recovery as a target outcome was evaluated on 4 occasions using the Fugl-Meyer assessment. Upper limb function, dexterity and spasticity were assessed using Action Research Arm Test, Box-Block Test and Modified Modified Ashworth Scale respectively. Occupational Performance/Satisfaction was assessed with Canadian Occupational Performance Measure and to assess neuroplasticity, Motor Evoked Potential was recorded by Transcranial Magnetic Stimulation. Visual analysis, slope, and percentage of non-overlapping data were used for assessing the changes between phases. Results: Percentage of non-overlapping data and slopes indicated that motor recovery had clinically relevant improvements after both interventions compared to baselines. Other outcomes also showed improvements except for spasticity of wrist/elbow flexors and Motor Evoked Potential of opponens indicis. Conclusion: Self-AOT may be as effective as other procedures of AOT for improving upper limb motor function, occupational performance/satisfaction, and cortical excitability post-stroke.

Muscle Selection and Dosing in a Phase 3, Pivotal Study of AbobotulinumtoxinA Injection in Upper Limb Muscles in Children With Cerebral Palsy.

Background: Guidelines recommend botulinum toxin-A in pediatric upper limb spasticity as part of routine practice. Appropriate dosing is a prerequisite for treatment success and it is important that injectors have an understanding on how to tailor dosing within a safe and effective range. We report upper limb dosing data from a phase 3 study of abobotulinumtoxinA injections in children with cerebral palsy.Methods: This was a double-blind, repeat-treatment study (NCT02106351). In Cycle 1, children were randomized to abobotulinumtoxinA at 2 U/kg control dose or clinically relevant 8 U/kg or 16 U/kg doses. Doses were divided between the primary target muscle group (PTMG, wrist or elbow flexors) and additional muscles tailored to clinical presentation. During Cycles 2–4, children received doses of 8 U/kg or 16 U/kg and investigators could change the PTMG and other muscles to be injected. Injection of muscles in the other upper limb and lower limbs was also permitted in cycles 2–4, with the total body dose not to exceed 30 U/kg or 1,000 U (whichever was lower) in the case of upper and lower limb treatment.Results: 212 children were randomized, of which 210 received ≥1 abobotulinumtoxinA injection. Per protocol, the elbow and wrist flexors were the most commonly injected upper limb muscles. Across all 4 cycles, the brachialis was injected in 89.5% of children (dose range 0.8–6 U/kg), the brachioradialis in 83.8% (0.4–3 U/kg), the flexor carpi ulnaris in 82.4% (0.5–3 U/kg) and the flexor carpi radialis in 79.5% (0.5–4 U/kg). Other frequently injected upper limb muscles were the pronator teres(70.0%, 0.3–3 U/kg). adductor pollicis (54.3%, 0.3-1 U/kg), pronator quadratus (44.8%, 0.1–2 U/kg), flexor digitorum superficialis (39.0%, 0.5-4 U/kg), flexor digitorum profundus (28.6%, 0.5–2 U), flexor pollicis brevis/opponens pollicis (27.6%, 0.3-1 U/kg) and biceps (27.1%, 0.5–6 U/kg). AbobotulinumtoxinA was well-tolerated at these doses; muscular weakness was reported in 4.3% of children in the 8 U/kg group and 5.7% in the 16 U/kg group.Conclusions: These data provide information on the pattern of injected muscles and dose ranges used in this study, which were well-tolerated. Per protocol, most children received injections into the elbow and wrist flexors. However, there was a wide variety of other upper limb muscles injected as physicians tailored injection patterns to clinical need.

Cerebellar Intermittent Theta-Burst Stimulation Reduces Upper Limb Spasticity After Subacute Stroke: A Randomized Controlled Trial.

Objective: This study aims to explore the efficacy of cerebellar intermittent theta-burst stimulation (iTBS) on upper limb spasticity in subacute stroke patients.Methods: A total of 32 patients with upper limb spasticity were enrolled and randomly assigned to treatment with cerebellar iTBS or sham stimulation before conventional physical therapy daily for 2 weeks. The primary outcomes included the modified Ashworth scale (MAS), the modified Tardieu scale (MTS), and the shear wave velocity (SWV). The secondary outcomes were the H-maximum wave/M-maximum wave amplitude ratio (Hmax/Mmax ratio), motor-evoked potential (MEP) latency and amplitude, central motor conduction time (CMCT), and the Barthel Index (BI). All outcomes were evaluated at baseline and after 10 sessions of intervention.Results: After the intervention, both groups showed significant improvements in the MAS, MTS, SWV, and BI. In addition, patients treated with cerebellar iTBS had a significant increase in MEP amplitude, and patients treated with sham stimulation had a significant decrease in Hmax/Mmax ratio. Compared with the sham stimulation group, the MAS, MTS, and SWV decreased more in the cerebellar iTBS group.Conclusion: Cerebellar iTBS is a promising adjuvant tool to reinforce the therapeutic effect of conventional physical therapy in upper limb spasticity management after subacute stroke (Chinese Clinical Trial Registry: ChiCTR1900026516).

Rebalancing the Spastic Wrist by Transposition of Antagonistic Muscle-Tendon Complex.

Upper limb spasticity and spasticity-induced deformities after upper motor neuron lesions because of traumatic brain injury, encephalitis or cerebral palsy inhibit activities of daily living, result in impaired self-care and often dependence on assistance of carers. A key element of the dysfunction is wrist hyper-flexion and ulnar deviation deformity. Traditionally, this deformity has been corrected by transfer of the spastic flexor carpi ulnaris to the extensor carpi radialis brevis. Instead, this study emphasizes the causative role of the palmar subluxation of extensor carpi ulnaris and describes a surgical correction strategy detailing transfer of extensor carpi ulnaris-to-extensor carpi radialis brevis. This surgery re-establishes and maintains a more favorable muscle-tendon-joint mechanics and hand position. Patient satisfaction is high, time and effort in daily care for patients and caregivers are less, and incidence of complications is low.

Convergent Validity and Test-Retest Reliability of Multimodal Ultrasonography and Related Clinical Measures in People With Chronic Stroke

ObjectiveTo assess the test-retest reliability of diagnostic ultrasonography measurements of the bilateral biceps brachii (BB), brachial artery, medial gastrocnemius (MG), and popliteal artery in survivors of stroke and their convergent validity with related clinical comparators. DesignCross-sectional study. SettingAll procedures were conducted in a university laboratory. ParticipantsSixty-five community dwelling adults (N=65; 26 women, 39 men) with an average age of 60.9±7.7 years and stroke duration of 5.7±3.9 years participated in this study. InterventionsNot applicable. Main Outcome MeasuresMeasures of muscle structure (ie, thickness, cross-sectional area, fascicle length, pennation angle), stiffness, and intramuscular blood perfusion were conducted using B-mode, elastography and color flow Doppler ultrasonography modes, respectively. Convergent validity was assessed by examining correlations between ultrasonography measures and assessments of related constructs (ie, dynamic stiffness, isometric peak torque, spasticity, and systemic vascular function using myotonometry, dynamometry, the Composite Spasticity Scale, and the Ankle-Brachial Index, respectively). A 2-way random-effects intraclass correlation coefficient (ICC) model (ICC2,3) was used to determine agreement between intersession measures among a smaller cohort of participants with stroke (n=20). ResultsICC estimates ranged from moderate to excellent for muscle stiffness (paretic: ICC=0.74-0.89; nonparetic: ICC=0.66-0.88), structure (paretic: ICC=0.87-0.99; nonparetic: ICC=0.81-0.98), and blood perfusion measures (paretic: ICC=0.74-0.84; nonparetic: ICC=0.73-0.88). Weak to moderate associations were found between myotonometry and elastography measures of the bilateral BB (r=0.29-0.52, P≤.05) and MG muscles (r=0.31-0.69, P≤.05). The correlations between elastography measures and spasticity scores for the paretic upper (r=0.35-0.63, P≤.05) and lower limbs (r=0.25-0.37, P≤.05) were also weak to moderate. ConclusionsElastography demonstrated mostly weak to moderate correlation with measures of stiffness using myotonometry as well as scores of paretic upper and lower limb spasticity. The results also indicate acceptable intersession reliability for muscle and vascular measures using several ultrasonography modalities among individuals with chronic stroke.