Wrist Flexor Spasticity Research Articles

Ultrasound visualization of Botulinum toxin injection: Identifying clinical correlates to optimize outcomes in spasticity management.

Botulinum toxin injections are well established and commonly used for spasticity management. Clinicians strive to optimize outcomes from toxin injections. One potential complication is toxin spread beyond the intended muscle, which can lead to unwanted weakness. The utilization of ultrasound allows direct visualization of target muscles and identification of toxin leakage from the target muscle. Ultrasound evaluation of clinical factors that correlate to toxin leakage have not been studied. To identify cases of botulinum toxin injectate leak beyond the targeted muscle during ultrasound-guided spasticity injections and associate cases of leak with predictive clinical factors, which include muscle size, fibroadipose changes, and number of previous injections. This was a prospective observational study. An outpatient clinic in an academic medical center. Patients who demonstrated wrist flexor spasticity warranting intervention were invited to participate. Patients received standard-of-care spasticity management with injection of onabotulinumtoxinA into the flexor carpi radialis muscle based upon clinical presentation and prescribing guidelines. Ultrasound video was recorded, and a blinded review was conducted by the study team. The primary outcome measure was visualized leak of injectate on recorded ultrasound video. Documented leak was then associated with clinical factors including diameter of the flexor carpi radialis, volume of injectate used, history of prior injections, and fibrotic change of the muscle. The study included 54 patients, 77.8% of whom had an underlying diagnosis of cerebrovascular accident. Injectate leak was observed in 18.5% of injections and could not be confirmed in 9.3% of injections. Multivariable analysis demonstrated increased odds of leak with higher Modified Heckmatt Scale score. No statistically significant increase in leak was noted with higher volume of injectate or smaller muscle diameter. Extramuscular leak of botulinum toxin injection may be associated with fibroadipose muscle change.

Responsiveness of the Australian Spasticity Assessment Scale to botulinum neurotoxin injection into spastic wrist flexors after acquired brain injury.

The Australian Spasticity Assessment Scale (ASAS) is a relatively new scale used to rate the severity of spasticity. Although the reliability of the ASAS has been investigated, its ability to detect a clinically important change (responsiveness) has not. The objective of this study was to investigate the responsiveness of the ASAS in adult patients with acquired brain injury-related wrist flexor spasticity treated with botulinum neurotoxin A. The responsiveness of the ASAS was assessed by the standardized response mean at the group level. At the individual level, responsiveness was assessed by the percentage of responders and nonresponders. Those who had at least a 1 grade reduction in spasticity severity were considered responders. In addition, the magnitude of the goniometric change in R1 (angle of catch response) across the responders and nonresponders was studied as a distribution of frequency. Significant improvements in R1 and ASAS were achieved with the treatment. The standardized response mean based on the ASAS grades was 1.50 with a 95% confidence interval of 1.16-1.89. At the individual level, 40 of all cases (78.4%) were responders, and 11 (21.6%) were nonresponders. Three of the 11 nonresponders (27.3%) improved R1 beyond the 10 ° margin of error (20, 50, and 50 °). In contrast, the percentage of responders who had a change within the margin of error was 27.5% (11 out of 40). Although ASAS can reveal a decrease in wrist flexor spasticity, it has some shortcomings in detecting the potentially clinically important response at the individual level.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial.

The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain. To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke. Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment. A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point. The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

Comparison of tendon and muscle belly vibratory stimulation in the treatment of post-stroke upper extremity spasticity: a retrospective observational pilot study

Previous studies have reported the effects of vibratory stimulation (VS) therapy in reducing upper extremity spasticity after stroke. However, the effective location of the VS in patients with stroke remains unclear. This study aimed to determine the VS location that is most effective in reducing post-stroke finger and wrist flexor spasticity. We enrolled 27 consecutive patients with stroke and upper extremity spasticity in this retrospective observational study. The participants received stretching, tendon vibration, and muscle belly vibration for 5 min over a period of 3 days. To evaluate spasticity, we assessed the Modified Ashworth Scale score before and immediately after each treatment and immediately after voluntary finger flexion. Participants who received tendon vibration showed greater improvement in flexor tone in the fingers than participants who received stretching and muscle belly vibration (P < 0.05 and < 0.001, respectively). Participants who underwent VS showed no significant improvement in the wrist flexor tone compared to those who underwent stretching. Our results suggest that the tendon may be the most effective location for treating spasticity of the finger flexor muscles and that VS may not significantly improve spasticity of the wrist flexors more than stretching.

A Clinical Trial Protocol to Compare the Effect of Dry Needling and Acupoint Dry Needling on Wrist Flexor Spasticity after Stroke.

Stroke is the leading cause of disability in adults worldwide, with spasticity after stroke being one of the more common complications. Dry needling (DN) has been demonstrated to decrease spasticity in stroke patients, although its effects on improving function remain unclear. The purpose of this study protocol is to compare the short-term effects of DN versus acupoint DN on wrist flexor spasticity and upper extremity function in patients with stroke. A double-blind, randomized clinical trial will be conducted to include patients with stroke and upper extremity spasticity and functional disability. Twenty-four patients with stroke will be randomly assigned to either the DN or acupoint DN (DNap) group. These groups will receive three DN sessions during a one-week period of the wrist flexor muscles or at the LI4 & TE5 acupoints, respectively. The primary outcome measure is the Modified Modified Ashworth Scale (MMAS) of spasticity. The secondary outcomes are the Fugl-Meyer Assessment of motor function (FMA) and the goniometry to assess the active and passive range of motion of the wrist. Data will be collected at baseline, immediately after the end of three sessions DN, and at a one-week follow-up visit. The results of this comparative study will help to determine the more effective method for reducing spasticity and improving motor function in patients with stroke.

Combined effects of dry needling and exercises therapy on muscle spasticity and motor function in chronic stroke: a pretest-posttest pilot study

Aim: Spasticity is one of the most common symptoms in post-stroke patients. Dry needling (DN) is a relatively new method for the management of muscle spasticity. A multimodal treatment may be more effective in spasticity management. The purpose of this study was to explore the short-term combined effects of DN and exercise therapy on wrist flexor spasticity, motor function, and motor neuron excitability in patients with chronic stroke. Methods: Ten patients with stroke and a mean age of 52 ± 4.9 years participated in this pretest-posttest pilot study. Patients received four sessions of DN and exercise therapy. Affected flexor carpi radialis and flexor carpi ulnaris muscles were needled each for 1 min. Patients underwent exercise therapy for about 30 min, once a week after DN. The outcome measures were the Modified Modified Ashworth Scale (MMAS), the maximal amplitude of H wave/maximal amplitude of M wave ratio (Hmax/Mmax Ratio), H-reflex latency, wrist extension active and passive range of motion (ROM), Action Research Arm Test (ARAT), and Fugl-Meyer Assessment (FMA). Assessments were performed at baseline, after four sessions of treatment, and three weeks after treatment. Results: After treatment, significant improvements in MMAS, wrist passive ROM, ARAT, and FMA were obtained (P ≤ 0.05). Conclusions: DN combined with exercise therapy improved muscle spasticity and motor function in patients with chronic stroke. Further investigations with a randomized controlled trial design with a comparator group of DN only are warranted (https://www.irct.ir/; IRCT ID: IRCT20180611040061N1).

Effects of Dry Needling on Connectivity of Corticospinal Tract, Spasticity, and Function of Upper Extremity in People with Stroke: Study Protocol for a Randomized Controlled Trial

Spasticity is a common motor disorder in adult stroke patients. Injury to the corticospinal tract (CST) is associated with spasticity. Dry needling (DN) has positive impacts on spasticity reduction and improvement in the range of motion (ROM) in stroke patients. This study aims to investigate the effectiveness of DN on the connectivity of the CST and the level of spasticity in adult stroke patients. This double-blind randomized controlled trial will enroll and randomly assign stroke patients to either the experimental group, for receiving three sessions of DN for the spastic wrist flexors, or the control group, for sham needling. The primary outcome measures will be diffusion tensor imaging and the Modified Modified Ashworth Scale score to assess CST connectivity and wrist flexor spasticity, respectively. The Box and Block Test and standard goniometry are the secondary outcome measures to assess hand dexterity and active and passive wrist ROM, respectively. Measurements will be taken both before and after the intervention. The results of this study will provide important evidence of the effects of DN on CST connectivity, spasticity, and arm function in adult stroke patients. This trial is registered in the Iranian Registry of Clinical Trials (IRCT) (https://www.irct.ir; IRCT20191208045649N1).

Effects of dry needling plus exercise therapy on post-stroke spasticity and motor function: A case report

Background and purposeThe use of dry needling (DN) with other treatments may be more beneficial in managing post-stroke spasticity. We report the effects of DN plus exercise therapy (ET) on wrist flexor spasticity. Patient presentationThe patient was a 45-year-old man with an 8-year history of stroke. The outcome measures included the Modified Modified Ashworth Scale (MMAS), Hmax/Mmax ratio, H-reflex latency, Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), and range of motion (ROM) which were assessed before (T1), after (T2), and after 3-week follow-up (T3). ConclusionThe MMAS was improved at T2 from “3” to “2”. The Hmax/Mmax decreased from 0.77 to 0.53 at T3. The H-reflex latency increased from 15.4 ms to 18.5 ms at T3. The wrist active and passive ROM increased ∼30° and ∼20° at T2, respectively.A 4-session DN plus ET may improve spasticity and ROM. No meaningful improvement was observed in function.

The Effect of Sham Controlled Continuous Theta Burst Stimulation and Low Frequency Repetitive Transcranial Magnetic Stimulation on Upper Extremity Spasticity and Functional Recovery in Chronic Ischemic Stroke Patients

ObjectiveThis randomized controlled study examined the effect of continuous theta burst stimulation (cTBS) and low frequency repetitive transcranial magnetic stimulation (rTMS) on upper extremity spasticity and functional recovery in chronic ischemic stroke patients. Materials and MethodsTwenty chronic ischemic stroke patients were randomized into three groups as real rTMS group (n = 7), real cTBS group (n = 7) and sham cTBS group (n = 6), in which real rTMS with physical therapy (PT), real cTBS with PT and sham cTBS with PT were applied in 10 sessions, respectively. The evaluation parameters were assessed at pre-treatment, post-treatment and follow up at 4 weeks. ResultsTen sessions of real rTMS or real cTBS combined with PT were found beneficial in motor functional recovery and daily living activities both at post-treatment and follow up at 4 weeks (p ˂ 0.05). In the sham cTBS group, functional improvement was not significant (p > 0.05). In addition, in the real rTMS group, elbow flexor, pronator, wrist flexor and finger flexor spasticity were significantly decreased; in the real cTBS group, significant decrease was observed in the elbow flexor and wrist flexor spasticity (p ˂ 0.05). In comparison with sham cTBS group, only in the real cTBS group, significant improvement was observed in the level of wrist flexor spasticity at follow up at 4 weeks (p ˂ 0.017). ConclusionsIn this study, it was observed that real cTBS or real rTMS combined with PT provided improvement on upper extremity motor functions and daily living activities in chronic ischemic stroke patients, but improvement in spasticity was limited.

Efficacy and Safety of MT10107 (Coretox) in Poststroke Upper Limb Spasticity Treatment: A Randomized, Double-Blind, Active Drug-Controlled, Multicenter, Phase III Clinical Trial

ObjectiveTo compare the efficacy and safety of MT10107 (Coretox) with those of onabotulinum toxin A (Botox) in patients with poststroke upper limb spasticity DesignProspective, randomized, double-blind, active drug-controlled, multicenter, phase III clinical trial. SettingSeven university hospitals in the Republic of Korea. ParticipantsPatients (N=220) with poststroke upper limb spasticity. InterventionsAll participants received a single injection of either MT10107 (Coretox group) or onabotulinum toxin A (Botox group). Main Outcome MeasuresThe primary outcome was change in wrist flexor spasticity from baseline to week 4, which was assessed using the modified Ashworth scale (MAS). The secondary outcomes were MAS scores for wrist, elbow, and finger flexors; percentage of treatment responders (response rate); Disability Assessment Scale (DAS) score, and global assessment of treatment. Safety was evaluated based on adverse events, vital signs, physical examination findings, and laboratory test results. The efficacy and safety were evaluated at 4, 8, and 12 weeks postintervention. ResultsThe primary outcome was found to be −1.32±0.69 and −1.40±0.69 for the Coretox and Botox groups, respectively. MT10107 showed a non-inferior efficacy compared with onabotulinum toxin A, as the 95% confidence interval for between-group differences was −0.10 to 0.27 and the upper limit was less than the non-inferiority margin of 0.45. Regarding the secondary outcomes, MAS scores for all muscles and DAS scores showed a significant improvement at all time points in both groups, with no significant between-group difference. No significant between-group differences were observed regarding response rate, global assessment of treatment, and safety measures. ConclusionsMT10107 showed no significant difference in efficacy and safety compared with onabotulinum toxin A in poststroke upper limb spasticity treatment.

Effects of spasticity and hemiplegic posture on median nerve and carpal tunnel in stroke patients: Electrophysiological and ultrasonographic evaluation

This study aims to evaluate whether the upper extremity spasticity and hemiplegic posture have any effect on the morphology of the carpal tunnel and median nerve in stroke patients. Nerve conduction studies (NCS) were performed in 46 stroke patients and compared to those of 30 healthy controls. The cross-sectional area (CSA) of the carpal tunnel (CT) and median nerve (wrist/mid-forearm levels) was assessed by ultrasonography. The mean ages of the stroke and control group were 55.6 ± 13.5 and 56 ± 12.1 years, respectively. The median spasticity score of the forearm pronators and wrist flexor muscles was 2 (0–4) according to the Modified Ashworth Scale (MAS). The compound muscle action potential (CMAP) of the median nerve was reduced (10,093 ± 4,451 mV) when compared to non-paretic side (11,615 ± 4,397 mV) (p:0.02) and the CSA of the CT was thinner on the paretic side (1.9 ± 0.3 cm2 vs 2.08 ± 0.2 cm2) (p:0.03). Pronator spasticity had no significant effect on the CSA of the median nerve and NCS at the forearm level. The CSA of the median nerve at the wrist was significantly thicker in patients with the wrist flexor spasticity graded II (MAS) and above compared to those with spasticity graded I and below (9.5 ± 1.7 mm2 and 8.7 ± 1.7 mm2 respectively) (p:0.03). However, the thickening of the median nerve didn’t cause significant abnormalities in NCS. This study shows that in stroke patients, wrist flexor spasticity and hemiplegic wrist posture can cause explicit morphological changes in the CT and median nerve albeit normal findings on NCS.

Test-retest reliability and responsiveness of isokinetic dynamometry to assess wrist flexor muscle spasticity in subacute post-stroke hemiparesis

IntroductionTo overcome the limitations of clinical scales, objective measurement methods are becoming prominent in spasticity assessment. The aim of this study was to assess the test–retest reliability and responsiveness of isokinetic dynamometry to evaluate wrist flexor spasticity in patients with subacute stroke. MethodsTwenty six patients with hemiparetic stroke (13 men, 13 women, mean age 51.38 ± 12.64 years) volunteered to take part in this study. Resistive torque in the wrist flexor muscles was measured twice, 1 day apart, with an isokinetic dynamometer. Wrist extension was tested at four speeds (5, 60, 120 and 180°/s). Torque response at the lowest speed (5°/s) was attributed to the non-neural component of the wrist flexor muscles, and was subtracted from the torque response at the higher speeds to calculate reflex torque (spasticity). The reliability of reflex torque measurements at 60, 120 and 180°/s was evaluated with the intraclass correlation coefficient (ICC2,1) and standard error of measurement (SEM and SEM%), which reflect reproducibility and measurement error, respectively. Responsiveness was calculated as the smallest real difference (SRD and SRD%). ResultsReproducibility was excellent at different movement speeds (ICC2, 1 0.76–0.85). SEM% ranged from 11% to 21%, and SRD% ranged from 30% to 58%. ICC values increased, and SEM% and SRD% decreased, as test speed increased. ConclusionOur results support the reliability and responsiveness of isokinetic dynamometry to quantify spasticity in wrist flexor muscles in patients with subacute stroke. Reliability and responsiveness increased as the speed of wrist movement increased.

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.

Effectiveness of static stretching positioning on post-stroke upper-limb spasticity and mobility: Systematic review with meta-analysis.

To systematically review the effects of static stretching with positioning orthoses or simple positioning combined or not with other therapies on upper-limb spasticity and mobility in adults after stroke. This meta-analysis was conducted according to PRISMA guidelines and registered at PROSPERO. MEDLINE (Pubmed), Embase, Cochrane CENTRAL, Scopus and PEDro databases were searched from inception to January 2018 for articles. Two independent researchers extracted data, assessed the methodological quality and rated the quality of evidence of studies. Three studies (57 participants) were included in the spasticity meta-analysis and 7 (210 participants) in the mobility meta-analysis. Static stretching with positioning orthoses reduced wrist-flexor spasticity as compared with no therapy (mean difference [MD]=-1.89, 95% confidence interval [CI] -2.44 to -1.34; I2 79%, P<0.001). No data were available concerning the spasticity of other muscles. Static stretching with simple positioning, combined or not with other therapies, was not better than conventional physiotherapy in preventing loss of mobility of shoulder external rotation (MD=3.50, 95% CI -3.45 to 10.45; I2 54.7%, P=0.32), shoulder flexion (MD=-1.20, 95% CI -8.95 to 6.55; I2 0%, P=0.76) or wrist extension (MD=-0.32, 95% CI -6.98 to 5.75; I2 38.5%, P=0.92). No data were available concerning the mobility of other joints. This meta-analysis revealed very low-quality evidence that static stretching with positioning orthoses reduces wrist flexion spasticity after stroke as compared with no therapy. Furthermore, we found low-quality evidence that static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist. Considering the limited number of studies devoted to this issue in post-stroke survivors, further randomized clinical trials are still needed. PROSPERO (CRD42017078784).

24-Hour Alberta Stroke Program Early CT Score Assessment in Post-Stroke Spasticity Development in Patients with a First Documented Anterior Circulation Ischemic Stroke

Neuroanatomic substrates responsible for development of post-stroke spasticity are still poorly understood. The study is focused on identification of brain regions within the territory of the middle cerebral artery associated with spasticity development. This is a single-center prospective cohort study of first documented anterior circulation ischemic strokes with a neurologic deficit lasting >7 days (from March 2014 to September 2016, all patients are involved in a registry). Ischemic cerebral lesions within the territory of middle cerebral artery were evaluated using the Alberta Stroke Program Early CT Score (ASPECTS) on control 24-hour computed tomography or magnetic resonance imaging. Spasticity was assessed with modified Ashworth scale. Seventy-six patients (mean age 72 years, 45% females; 30% treated with IV tissue plasminogen activator, 6.5% mechanical thrombectomy) fulfilled the study inclusion criteria. Forty-nine (64%) developed early elbow or wrist flexor spasticity defined as modified Ashworth scale >1 (at day 7-10), in 44 (58%) the spasticity remained present at 6 months. There were no differences between the patients who developed spasticity and those who did not when comparing admission stroke severity (National Institutes of Health Stroke Scale 5 [interquartile range {IQR} 4-8] versus 6 [IQR 4-10]) and vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, coronary artery disease). Nor was there a difference in 24-hour ASPECTS score (9 [IQR 8-10] versus 9 [IQR 7-10]). No differences were found between the groups with and without the early upper limb flexor spasticity of particular regions (M1, M2, M3, M4, M5, M6, lentiform, insula, caudate, internal capsule) and precentral-postcentral gyrus, premotor cortex, supplementary motor area, posterior limb of internal capsule, and thalamus were compared. We did not find any middle cerebral artery territory associated with post-stroke spasticity development by detailed evaluation of ASPECTS.

A Randomized Controlled Study: Effectiveness of Functional Electrical Stimulation on Wrist and Finger Flexor Spasticity in Hemiplegia

The objective of this study was to investigate the effectiveness of functional electrical stimulation (FES) applied to the wrist and finger extensors for wrist flexor spasticity in hemiplegic patients. Thirty stroke patients treated as inpatients were included in the study. Patients were randomly divided into study and control groups. FES was applied to the study group. Wrist range of movement, the Modified Ashworth Scale (MAS), Rivermead Motor Assessment (RMA), Brunnstrom (BS) hand neurophysiological staging, Barthel Index (BI), and Upper Extremity Function Test (UEFT) are outcome measures. There was no significant difference regarding range of motion (ROM) and BI values on admission between the groups. A significant difference was found in favor of the study group for these values at discharge. In the assessment within groups, there was no significant difference between admission and discharge RMA, BS hand, and UEFT scores in the control group, but there was a significant difference between the admission and discharge values for these parameters in the study group. Both groups showed improvement in MAS values on internal assessment. It was determined that FES application is an effective method to reduce spasticity and to improve ROM, motor, and functional outcomes in hemiplegic wrist flexor spasticity.

Repetitive Peripheral Magnetic Stimulation (rpMS) in Combination with Muscle Stretch Decreased the Wrist and Finger Flexor Muscle Spasticity in Chronic Patients after CNS Lesion

Objective: The study assessed the effect of a single session of repetitive peripheral magnetic stimulation (rpMS) combined with manual stretch on wrist and finger flexor muscle spasticity. Methods: Forty chronic patients after CNS lesion with a severe wrist and finger flexor spasticity with a Modified Ashworth Score (MAS, 0-5) of either 2, 3 or 4 participated and formed two groups. A single session of rpMS (A) or sham (B) (5 Hz, Intensity 60% or 0%, 3s trains, 750 stimuli delivered within five minutes) was applied in an A-B (group I) or B-A (group II) design. A 30 min baseline (90 min follow-up) proceeded (followed) A or B. During the intervention, the wrist and metatarsophalangeal (MCP) joints were stretched manually. Primary variable was the wrist and finger flexor spasticity, assessed with the help of the Modified Ashworth Score (MAS, 0-5), by a rater blinded to treatment allocation. A- and B-data were pooled irrespective of group assignment. Results: At study onset, both groups were homogeneous. Following rpMS but not sham, the wrist and finger MAS significantly decreased over time. Accordingly, the MAS of the rpMS group was significantly less at t+5 min (wrist p=0.002, MCP joints p<0.001) and at t+90 min (MCP joints p=0.002). No side effects occurred. Conclusion: A single session of rpMS but not sham in combination with manual stretch significantly reduced the wrist and finger flexor muscle spasticity in chronically CNS-lesioned patients. Long-term studies including an rpMS group only should follow.

Effects of combining robot-assisted therapy with neuromuscular electrical stimulation on motor impairment, motor and daily function, and quality of life in patients with chronic stroke: a double-blinded randomized controlled trial.

BackgroundRobot-assisted therapy (RT) is a widely used intervention approach to enhance motor recovery in patients after stroke, but its effects on functional improvement remained uncertain. Neuromuscular electrical stimulation (NMES) is one potential adjuvant intervention approach to RT that could directly activate the stimulated muscles and improve functional use of the paretic hand.MethodsThis was a randomized, double-blind, sham-controlled study. Thirty-nine individuals with chronic stroke were randomly assigned to the RT combined with NMES (RT + ES) or to RT with sham stimulation (RT + Sham) groups. The participants completed the intervention 90 to 100 minutes/day, 5 days/week for 4 weeks. The outcome measures included the upper extremity Fugl-Meyer Assessment (UE-FMA), modified Ashworth scale (MAS), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL), and Stroke Impact Scale 3.0 (SIS). All outcome measures were assessed before and after intervention, and the UE-FMA, MAL, and SIS were reassessed at 3 months of follow-up.ResultsCompared with the RT + Sham group, the RT + ES group demonstrated greater improvements in wrist flexor MAS score, WMFT quality of movement, and the hand function domain of the SIS. For other outcome measures, both groups improved significantly after the interventions, but no group differences were found.ConclusionRT + ES induced significant benefits in reducing wrist flexor spasticity and in hand movement quality in patients with chronic stroke.Trial registrationClinicalTrials.gov. NCT01655446

Single event multi level orthopedic surgery in a teenager having spastic triplegic cerebral palsy

An 18-year-old boy with spastic triplegic cerebral palsy was not able to stand or walk without support (GMF Score: Level-4) and even not able to hold things with his right hand. He had undergone orthopedic surgeries previously twice in both the lower limbs and right upper limb. He also underwent static magnetic field (SMF) of median nerve for pronator and wrist flexor spasticity in right upper limb. Single Event Multilevel Orthopedic Surgeries (SEMLOS) were performed in both the lower limbs and in right upper limb with derotational osteotomy on right proximal femur and fixation with DHS. On complete reassessment 1 month after the surgery it was found that he also had lots of trouble in sensory feedback. He was given first sensory integration followed by other therapeutic exercises. Now, he is fully independent and is able to walk with elbow crutches as well as two stick support for a long distance (GMF Score- level 3). Grip as well as release of fingers in right hand have also improved.

Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled trial

Objective: To compare the effectiveness of two procedures increasing the botulinum toxin type A effect for wrist and finger flexor spasticity after stroke. Design: A single-blind randomized trial. Subjects: Seventy patients with upper limb post-stroke spasticity. Methods: Adults with wrist and finger flexor muscles spasticity after stroke were submitted to botulinum toxin type A therapy. After the treatment, the subjects injected were randomly divided into two groups and submitted to adhesive taping (Group A) or daily muscle manual stretching, passive articular mobilization of wrist and fingers, and palmar splint (Group B) for 10 days. We measured spasticity with Modified Ashworth Scale, related disability with Disability Assessment Scale, and fingers position at rest. The measurements were done at baseline, after two weeks, and after one month from the treatment session. Results: After two weeks, subjects in Group A reported a significantly greater decrease in spasticity scores (Modified Ashworth Scale fingers: mean (standard deviation) 1.3±0.6 vs. 2.1±0.6; Modified Ashworth Scale wrist: 1.7 ±0.6 vs. 2.3 ±0.8), and after one month in spasticity and disability scores (Modified Ashworth Scale fingers: mean (standard deviation) 1.9 ±0.7 vs. 2.5 ±0.6; Modified Ashworth Scale wrist: 2.0 ±0.7 vs. 2.6 ±0.6; Disability Assessment Scale: 1.6 ±0.7 vs. 2.1 ±0.7) compared with Group B subjects. Subjects in Group A reported also a significantly improved fingers position at rest compared with Group B subjects after two weeks (2.8 ±0.9 vs. 2.1 ±0.7) and one month (2.3 ±0.7 vs. 1.5 ±0.6). Conclusions: Adhesive taping of wrist and finger flexor muscles appeared to enhance the effect of botulinum toxin type A therapy more than daily manual muscle stretching combined with passive articular mobilization and palmar splint.