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Béseler Soto MR, Montes García J, Máñez Añón I. [Stroke spasticity: Is age a risk factor? Observational study of spasticity in neurovascular patients in a retrospective series of two health sites]. Rev Esp Geriatr Gerontol 2020; 55:258-265. [PMID: 32768255 DOI: 10.1016/j.regg.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Approximately one third of patients who have suffered a stroke develop spasticity. Since clinical observations that spasticity in the elderly population is lower after stroke, and disagreement about risk factors between different authors, an analysis is performed on the variables that influence the development of spasticity. The objective of the study is to determine the how many factors influence spasticity outcome, and the prevalence of spasticity in patients who have suffered a stroke and require intensive rehabilitation treatment. METHOD A retrospective assessment was carried out on a total of 554 patients from two neurorehabilitation centres. A record was made of sociodemographic data, aetiology, type and location of stroke, motor and sensory deficits, language and swallowing impairment, incontinence, cognitive and mood state. Spasticity levels at admission and at the third month were studied in 462 patients using the Ashworth scale. Multivariate regression analyses were used to assess the risk factors for spasticity present at the third month after stroke. RESULTS The mean age of the patients was 67.3 years, of which 67.1% were men, and with ischemic aetiology in 76.5%. On admission 31.4% of patients had spasticity, and this increased to 54.8% at the 3rd month. The absolute risk factor for spasticity was motor index (OR 1.04; 95% CI 1.03-1.05). When this factor was omitted, the variables with predictive ability were: age less than 75 years (OR 0.52; 95% CI 0.30-0.90), sensory impairment (OR 0.66; 95% CI 0.37-1.20), and lower Barthel index score (OR 1.02; 95% CI 1.01-1.03). There was no significant relationship for gender, physiopathological mechanism (ischaemic/haemorrhagic), stroke location, aphasia, or cognitive impairment. CONCLUSION The prevalence of spasticity in stroke at third month of follow-up was 54.8%. Motor index is the independent predictor of spasticity. Patients younger than 75 years old, with sensory impairment and low Barthel index score are more likely to develop spasticity.
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Affiliation(s)
- M Rosario Béseler Soto
- Servicio de Medicina Física y Rehabilitación, Hospital Universitari Dr. Peset, Valencia, España.
| | - José Montes García
- Departamento de Biometría, Effice Servicios para la Investigación S.L., Madrid, España
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Simpson C, Huerta B, Sketch S, Lansberg M, Hawkes E, Okamura A. Upper Extremity Exomuscle for Shoulder Abduction Support. ACTA ACUST UNITED AC 2020. [DOI: 10.1109/tmrb.2020.3012471] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Rizzoglio F, Pierella C, De Santis D, Mussa-Ivaldi F, Casadio M. A hybrid Body-Machine Interface integrating signals from muscles and motions. J Neural Eng 2020; 17:046004. [PMID: 32521522 DOI: 10.1088/1741-2552/ab9b6c] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Body-Machine Interfaces (BoMIs) establish a way to operate a variety of devices, allowing their users to extend the limits of their motor abilities by exploiting the redundancy of muscles and motions that remain available after spinal cord injury or stroke. Here, we considered the integration of two types of signals, motion signals derived from inertial measurement units (IMUs) and muscle activities recorded with electromyography (EMG), both contributing to the operation of the BoMI. APPROACH A direct combination of IMU and EMG signals might result in inefficient control due to the differences in their nature. Accordingly, we used a nonlinear-regression-based approach to predict IMU from EMG signals, after which the predicted and actual IMU signals were combined into a hybrid control signal. The goal of this approach was to provide users with the possibility to switch seamlessly between movement and EMG control, using the BoMI as a tool for promoting the engagement of selected muscles. We tested the interface in three control modalities, EMG-only, IMU-only and hybrid, in a cohort of 15 unimpaired participants. Participants practiced reaching movements by guiding a computer cursor over a set of targets. MAIN RESULTS We found that the proposed hybrid control led to comparable performance to IMU-based control and significantly outperformed the EMG-only control. Results also indicated that hybrid cursor control was predominantly influenced by EMG signals. SIGNIFICANCE We concluded that combining EMG with IMU signals could be an efficient way to target muscle activations while overcoming the limitations of an EMG-only control.
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Affiliation(s)
- Fabio Rizzoglio
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, University of Genoa, 16145, Genoa, Italy. Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, United States of America. Shirley Ryan Ability Lab, Chicago, IL 60611, United States of America. Author to whom any correspondence should be addressed
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Nie J, Wang H, Jiang QW, Zhang Y, Zhang ZG, Mei M. Electrical stimulation for limb spasticity in children with stroke: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e21042. [PMID: 32629729 PMCID: PMC7337567 DOI: 10.1097/md.0000000000021042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND This systematic review protocol will appraise the effectiveness and safety of electrical stimulation (ES) for limb spasticity (LS) in children with stroke. METHODS Cochrane Library, EMBASE, PUBMED, PsycINFO, Scopus, OpenGrey, CINAHL, ACMD, CNKI, and WANGFANG will be systematically retrieved for randomized controlled trials (RCTs) testing the effectiveness of ES compared with other interventions on LS in children with stroke. Two independent authors will evaluate eligibility using predefined criteria and will perform data extraction and study quality appraisal of eligible trials. Primary outcomes include gait velocity, and limb spasticity status. Limb function, quality of life, pain intensity, and adverse events will be assessed as secondary outcomes. We will perform data analysis using RevMan 5.3 software. RESULTS This systematic review will summarize the most recent evidence to assess the effectiveness and safety of ES for LS in children with stroke. CONCLUSIONS The results of this study may help to determine whether ES is effective or not for LS in children with stroke. STUDY REGISTRATION INPLASY202050115.
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Affiliation(s)
- Jing Nie
- First Ward of Pediatrics Department
| | - He Wang
- Department of Neurosurgery, First Affiliated Hospital of Jiamusi University, Jiamusi
| | - Quan-Wei Jiang
- Department of Anesthesiology, Benxi Central Hospital, Benxi
| | - Ying Zhang
- Department of Neurology, Third Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin
| | - Zhi-Guang Zhang
- Department of Neurology, Hongda Hospital of Jiamusi University, Jiamusi, China
| | - Mei Mei
- First Ward of Pediatrics Department
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Doussoulin A, Bacco JL, Rivas C, Saiz JL. Association between postural patterns of spastic upper extremity and functional independence after TBI and stroke. NeuroRehabilitation 2020; 46:551-559. [PMID: 32508335 DOI: 10.3233/nre-203042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spastic hypertonia of the upper limb after stroke or traumatic brain injuries (TBI) is a prevalent clinical sign causing abnormal postures and movement patterns due to hyperexcitability of the upper motor neurons and rheological alterations in the affected muscles. These alterations limit the use of the upper limb, restricting its functional activities and affecting the individual's quality of life and social participation. OBJECTIVE To determine the association between spastic patterns of the upper limb, wrist, fingers and thumb, and independence in everyday activities after a stroke or TBI. METHODS The design is a cross-sectional descriptive and correlational study. The sample consisted of 206 individuals who complied with the eligibility criteria and signed an informed consent. Clinical evaluation was carried out, including determination of the postural pattern of the upper extremity according to Hefter's taxonomy and postural pattern classification of the wrist, fingers and thumb. Functional independence was evaluated using the Functional Independence Measure (FIM) and the Barthel Index (BI). RESULTS Univariate between-subject ANOVAs were used to examine associations of the four pattern classifications with the two independence measures, FIM and BI. Results indicate that Pattern I of Hefter's upper limb taxonomy is associated with lesser functional independence according to FIM and BI mean scores. CONCLUSIONS The postural pattern of the upper limb after TBI or stroke is related to the patient's functional independence. Specifically, Pattern I tends to co-occur with low independence.
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Affiliation(s)
- Arlette Doussoulin
- Department of Pediatrics and Child Surgery, Universidad de La Frontera, Temuco, Chile
| | | | | | - José L Saiz
- Department of Psychology, Universidad de La Frontera, Temuco, Chile
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Lee J, Chun MH, Ko YJ, Lee SU, Kim DY, Paik NJ, Kwon BS, Park YG. Efficacy and Safety of MT10107 (Coretox) in Poststroke Upper Limb Spasticity Treatment: A Randomized, Double-Blind, Active Drug-Controlled, Multicenter, Phase III Clinical Trial. Arch Phys Med Rehabil 2020; 101:1485-1496. [PMID: 32497599 DOI: 10.1016/j.apmr.2020.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/29/2020] [Accepted: 03/31/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of MT10107 (Coretox) with those of onabotulinum toxin A (Botox) in patients with poststroke upper limb spasticity DESIGN: Prospective, randomized, double-blind, active drug-controlled, multicenter, phase III clinical trial. SETTING Seven university hospitals in the Republic of Korea. PARTICIPANTS Patients (N=220) with poststroke upper limb spasticity. INTERVENTIONS All participants received a single injection of either MT10107 (Coretox group) or onabotulinum toxin A (Botox group). MAIN OUTCOME MEASURES The 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. RESULTS The 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. CONCLUSIONS MT10107 showed no significant difference in efficacy and safety compared with onabotulinum toxin A in poststroke upper limb spasticity treatment.
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Affiliation(s)
- Junekyung Lee
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - Min Ho Chun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul.
| | - Young Jin Ko
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
| | - Shi-Uk Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, Seoul
| | - Deog Young Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul
| | - Nam-Jong Paik
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Bum Sun Kwon
- Department of Rehabilitation Medicine, Dongguk University Ilsan Hospital, Goyang
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital Yonsei University College of Medicine, Seoul, Republic of Korea
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Zhang Q, Wang Y, Ji G, Cao F, Hu G, Cong D, Xu X, Song B. Standardization of rehabilitation program for post-apoplectic limb spasm treated by Tongjing Tiaoxing tuina and scalp acupuncture with physical therapy. Medicine (Baltimore) 2020; 99:e20368. [PMID: 32481332 PMCID: PMC7250062 DOI: 10.1097/md.0000000000020368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tong Jing Tiao Xing tuina (TJTX) is a Chinese massage method. Excising with scalp acupuncture (ESA) is a treatment combining scalp electroacupuncture with physical therapy (PT), and yinao fujian formula (YNFJ) is a Chinese oral herbal granule medicine. The combination of the 3 methods is called the "Zhishen Tiaoxing" (ZSTX) rehabilitation program, which is used as an alternative of limb spasm after stroke. There is little available evidence demonstrating its safety and efficacy. METHODS This will be a subject-blind, randomized controlled trial conducted in 3 medical centers. It will strictly follow the Standards for Reporting Interventions in Clinical Trials of Acupuncture, 2010. We will recruit 316 patients with limb spasm after stroke, 200 from the Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China, 80 from the Second Affiliated Hospital of Heilongjiang University of Chinese medicine, Harbin, China, and 36 from Huashan Hospital of Fudan University, Shanghai, China. A block randomization sequence stratified by centers will be generated using SAS Version 9.2 software (SAS Institute, Cary, NC, USA), which was performed at the Guangdong Provincial Hospital of Chinese Medicine's Key Unit of Methodology in Clinical Research. The treatment group is treated with TJTX (once a day), ESA (once a day), and oral YNFJ (twice a day). The control group will be treated with PT. Two groups of patients will be treated 5 sessions a week for 4 weeks, and there will be 6-month follow-up. The outcome evaluators will be blinded to patient grouping. The primary outcome will be modified Ashworth scales. The secondary outcome indexes will be the simplified Fugl-Meyer assessment scale, surface electromyogram root mean square value, modified Barthel index, stroke-specific quality of life scale, health scale of traditional Chinese medicine, visual analogue scale (VAS), and the Hamilton depression scale. DISCUSSION The Randomized Controlled Trial (RCT) mainly aim to evaluate the effectiveness and safety of traditional Chinese medicine rehabilitation program, by comparing the treatment of ZSTX with the PT for the treatment of limb spasm after stroke. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR 1900024255. Registered on July 3, 2019.
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Affiliation(s)
- Qiongshuai Zhang
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine
| | - Yufeng Wang
- Department of Tuina, Traditional Chinese Medicine Hospital of Jilin Province
| | - Guangcheng Ji
- Department of Rehabilitation, The Third Affiliated Hospital of Changchun University of Chinese Medicine, Changchun
| | - Fang Cao
- Department of Acupuncture, The 1st affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Guanyu Hu
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine
| | - Deyu Cong
- Department of Tuina, Traditional Chinese Medicine Hospital of Jilin Province
| | - Xiaohong Xu
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine
| | - Bailin Song
- Department of Acupuncture and Tuina, Changchun University of Chinese Medicine
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Reeves ML, Chotiyarnwong C, Nair KPS, Slovak M, Healey TJ, McCarthy AD, Patterson L, Lavender K, Strachan L, Ali AN, Baster K. Caregiver Delivered Sensory Electrical Stimulation for Post Stroke Upper Limb Spasticity: A Single Blind Crossover Randomized Feasibility Study. HEALTH AND TECHNOLOGY 2020. [DOI: 10.1007/s12553-020-00436-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AbstractWe developed a 64 channel sensory electrical stimulator which delivers a dynamic and variable ‘Sensory Barrage’ Stimulation (SBS). Our aim was to assess the feasibility of caregivers delivering the stimulation in the community for a clinical trial comparing single channel Transcutaneous Electrical Nerve Stimulation (TENS) with SBS for post stroke upper limb spasticity. We trained caregivers of 16 participants with post stroke upper limb spasticity to sequentially administer SBS and TENS for 60 min daily for four weeks each, with a washout period of two weeks in between. Outcome measures tested were recruitment and retention rates, compliance with interventions and daily recording of Participant -reported Numerical Rating Scale (NRS). We also collected results of Action Research Arm Test (ARAT), Leeds Arm Spasticity Impact Scale (LASIS) and Modified Ashworth Scale (MAS) for spasticity. Out of 21 potential participants, 16 consented and 15 completed the protocol. Ten participants received TENS for 80% (23/28) of the intended hours. Eleven participants completed NRS for at 80% (45/56) of the study days. All participants attended all visits. The MAS reduced by at least one in five participants after SBS and in three after TENS. Minimal Clinically Important Difference (MCID) of four points increase in ARAT was seen in five participants following TENS, and in four following SBS. A MCID of 18% decrease in NRS was reported by eight participants after TENS and three after SBS. This study demonstrated the feasibility of undertaking a trial of sensory electrical stimulation for post-stroke spasticity with caregivers delivering intervention in community. The study was not powered to detect efficacy of the interventions. Trial registration number: NCT02907775.Date 20-9-2016.
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Kagaya H, Masakado Y, Saitoh E, Fujiwara T, Abo M, Izumi SI, Nodera H, Dekundy A, Hiersemenzel R, Nalaskowski CM, Hanschmann A, Kaji R. IncobotulinumtoxinA for upper- and lower-limb spasticity in Japanese patients. Curr Med Res Opin 2020; 36:827-834. [PMID: 32141787 DOI: 10.1080/03007995.2020.1740187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: The safety and tolerability of incobotulinumtoxinA 400 U for upper- and lower-limb post-stroke spasticity was assessed in a small cohort of Japanese patients during the open-label lead-in tolerability periods (LITP) of two phase 3 studies (CTI-153029 and CTI-153030; Japan Pharmaceutical Information Centre).Methods: Adult patients received a single incobotulinumtoxinA injection session (total dose of 400 U) in the upper (J-PURE) or lower limb (J-PLUS). Adverse events (AEs) were assessed at 1, 4, 8 and 12 weeks post-injection during the 12 week follow-up.Results: The LITP of J-PURE and J-PLUS included 11 patients each. Mild/moderate AEs were reported by 5/11 (45.5%) and 8/11 (72.7%) patients in J-PURE and J-PLUS, respectively. No serious AEs were reported. Non-serious, transient AEs of special interest reported by two patients in J-PURE comprised muscular weakness and eyelid ptosis. No patient discontinued due to AEs.Conclusion: Preliminary results in this small population suggest that incobotulinumtoxinA 400 U is well tolerated for treating upper- or lower-limb post-stroke spasticity in Japanese patients.
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Affiliation(s)
- Hitoshi Kagaya
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Aichi, Japan
| | - Yoshihisa Masakado
- Department of Rehabilitation Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Eiichi Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Aichi, Japan
| | - Toshiyuki Fujiwara
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | | | | | | | | | - Ryuji Kaji
- Tokushima University Hospital, Tokushima, Japan
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Kongwattanakul K, Hiengkaew V, Jalayondeja C, Sawangdee Y. A structural equation model of falls at home in individuals with chronic stroke, based on the international classification of function, disability, and health. PLoS One 2020; 15:e0231491. [PMID: 32275692 PMCID: PMC7147784 DOI: 10.1371/journal.pone.0231491] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To use structural equation model (SEM) to explain falls at home in individuals with chronic stroke, based on the International Classification of Functioning, Disability and Health (ICF). MATERIALS AND METHODS A cross sectional observation study was conducted in home-dwelling individuals with chronic stroke (N = 236; 148 non-fallers, 88 fallers). Participants were assessed; structural impairments using Modified Ashworth Scale, Fugl-Meyer Assessment upper (FMA-UE), lower (FMA-LE), and sensory function, ankle plantarflexor strength; activity limitations using Timed Up and Go Test, Step Test, Berg Balance Scale, Barthel Index (BI); participation restrictions using Stroke Impact Scale-participation (SIS-P); and contextual factors using home hazard environments, home safety surroundings, risk behaviors, and Fall-related Self Efficacy. The measurement model was analyzed by confirmatory factor analysis. The SEM was conducted to analyze a structural model of falls at home. RESULTS FMA-UE was significantly (p<0.01) associated with FMA-LE, combining as one variable in the structural impairments. In the measurement model, variables were fit to their domains, except variables of contextual factors, but the ICF domains did not correspond to disability. A structural model of falls at home demonstrated a significant (p<0.01) direct path of contextual factors and activity limitations with falls at home. The structural impairments showed a significant (p<0.01) direct path with activity limitations. All variables, except BI, SIS-P and risk behaviors, related to their domains in the structural model. CONCLUSIONS A structural model of falls at home proposes contextual factors being the strongest association with falls at home that home hazard environments seem the most influence in its domain. The activity limitations presented by balance ability are directed to falls at home. The structural impairments are associated with falls at home through activity limitations. Home assessment to decrease home hazard environments is suggested to prevent falls at home for individuals with chronic stroke.
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Affiliation(s)
| | - Vimonwan Hiengkaew
- Faculty of Physical Therapy, Mahidol University, Salaya, Nakhon Pathom, Thailand
- * E-mail:
| | - Chutima Jalayondeja
- Faculty of Physical Therapy, Mahidol University, Salaya, Nakhon Pathom, Thailand
| | - Yothin Sawangdee
- Institute for Population and Social Research, Mahidol University, Salaya, Nakhon Pathom, Thailand
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Kerstens HCJW, Satink T, Nijkrake MJ, De Swart BJM, Nijhuis-van der Sanden MWG, Van der Wees PJ, Geurts ACH. Experienced consequences of spasticity and effects of botulinum toxin injections: a qualitative study amongst patients with disabling spasticity after stroke. Disabil Rehabil 2020; 43:3688-3695. [PMID: 32255361 DOI: 10.1080/09638288.2020.1746843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: Chronic spasticity poses a major burden on patients after stroke. Intramuscular botulinum toxin injections constitute an important part of the treatment for patients suffering from troublesome focal spasticity. This study explores the experienced consequences of chronic spasticity amongst patients after stroke regarding physical impairments and activities, the experienced effects of botulinum toxin treatment on these domains, and whether current spasticity management addresses patients' needs.Materials and methods: Fourteen participants with chronic spasticity after stroke who were treated with cyclical botulinum toxin injections in the upper and/or lower extremity muscles were interviewed. Inductive thematic analysis generated representative themes.Results: Analyses of the interviews revealed three themes: (1) spasticity-related impairments and activity limitations; (2) fluctuations in spasticity related to botulinum toxin; (3) need for professional support and feedback. Besides motor impairments, participants experienced activity limitations in many domains of everyday life, with considerable day-to-day fluctuations. Moreover, treatment with botulinum toxin led to cyclical fluctuations in spasticity-related symptoms, which differed across participants. The participants called for shared responsibility for treatment, particularly regarding optimising the timing of injections.Conclusion: Incorporating patient-relevant outcomes into the current assessment of spasticity and monitoring these outcomes may improve spasticity management, particularly regarding the timing of botulinum toxin injections.Implications for rehabilitationBecause chronic spasticity after stroke impacts on almost all domains of everyday life, professionals should identify and target the most relevant problems in each individual patient.Monitoring patient-reported outcomes may help patients and professionals to get insight in the fluctuations of spasticity-related symptoms and may help to evaluate the effects of botulinum toxin injections from the patient's perspective.Patient education and providing insight in the fluctuations of spasticity-related symptoms may support self-management and shared decision-making in spasticity management.
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Affiliation(s)
- Hans C J W Kerstens
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands.,HAN University of Applied Sciences, Nijmegen, Netherlands
| | - Ton Satink
- HAN University of Applied Sciences, Nijmegen, Netherlands
| | - Maarten J Nijkrake
- Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Bert J M De Swart
- HAN University of Applied Sciences, Nijmegen, Netherlands.,Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands.,Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, Netherlands
| | - Alexander C H Geurts
- Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
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Enhancing Stroke Recovery Across the Life Span With Noninvasive Neurostimulation. J Clin Neurophysiol 2020; 37:150-163. [DOI: 10.1097/wnp.0000000000000543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Wissel J, Fheodoroff K, Hoonhorst M, Müngersdorf M, Gallien P, Meier N, Hamacher J, Hefter H, Maisonobe P, Koch M. Effectiveness of AbobotulinumtoxinA in Post-stroke Upper Limb Spasticity in Relation to Timing of Treatment. Front Neurol 2020; 11:104. [PMID: 32184753 PMCID: PMC7058702 DOI: 10.3389/fneur.2020.00104] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Recent studies of botulinum toxin for post-stroke spasticity indicate potential benefits of early treatment (i. e., first 6 months) in terms of developing hypertonicity, pain and passive function limitations. This non-interventional, longitudinal study aimed to assess the impact of disease duration on the effectiveness of abobotulinumtoxinA treatment for upper limb spasticity. Methods: The early-BIRD study (NCT01840475) was conducted between February 2013 and 2018 in 43 centers across Germany, France, Austria, Netherlands and Switzerland. Adult patients with post-stroke upper limb spasticity undergoing routine abobotulinumtoxinA treatment were followed for up to four treatment cycles. Patients were categorized by time from stroke event to first botulinum toxin-A treatment in the study (as defined by the 1st and 3rd quartiles time distribution) into early-, medium- and late- start groups. We hypothesized that the early-start group would show a larger benefit (decrease) as assessed by the modified Ashworth scale (MAS, primary endpoint) on elbow plus wrist flexors compared with the late-start group. Results: Of the 303 patients enrolled, 292 (96.4%) received ≥1 treatment and 186 (61.4%) received 4 injection cycles and completed the study. Patients in all groups showed a reduction in MAS scores from baseline over the consecutive injection visits (i.e., at end of each cycle). Although reductions in MAS scores descriptively favored the early treatment group, the difference compared to the late group did not reach statistical significance at the last study visit (ANCOVA: difference in adjusted means of 0.15, p = 0.546). Conclusions: In this observational, routine-practice study, patients in all groups displayed a benefit from abobotulinumtoxinA treatment, supporting the effectiveness of treatment for patients at various disease stages. Although the data revealed some trends in favor of early vs. late treatment, we did not find strong evidence for a significant benefit of early vs. late start of treatment in terms of reduction in MAS scores.
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Affiliation(s)
| | | | | | - Martina Müngersdorf
- Neurologisches Zentrum für Bewegungsstörungen und Diagnostik, Berlin, Germany
| | | | - Niklaus Meier
- Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland
| | | | - Harald Hefter
- Department of Neurology, University of Düsseldorf, Düsseldorf, Germany
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64
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Enslin JMN, Rohlwink UK, Figaji A. Management of Spasticity After Traumatic Brain Injury in Children. Front Neurol 2020; 11:126. [PMID: 32153498 PMCID: PMC7047214 DOI: 10.3389/fneur.2020.00126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/04/2020] [Indexed: 11/24/2022] Open
Abstract
Traumatic brain injury is a common cause of disability worldwide. In fact, trauma is the second most common cause of death and disability, still today. Traumatic brain injury affects nearly 475 000 children in the United States alone. Globally it is estimated that nearly 2 million people are affected by traumatic brain injuries every year. The mechanism of injury differs between countries in the developing world, where low velocity injuries and interpersonal violence dominates, and high-income countries where high velocity injuries are more common. Traumatic brain injury is not only associated with acute problems, but patients can suffer from longstanding consequences such as seizures, spasticity, cognitive and social issues, often long after the acute injury has resolved. Spasticity is common after traumatic brain injury in children and up to 38% of patients may develop spasticity in the first 12 months after cerebral injury from stroke or trauma. Management of spasticity in children after traumatic brain injury is often overlooked as there are more pressing issues to attend to in the early phase after injury. By the time the spasticity becomes a priority, often it is too late to make meaningful improvements without reverting to major corrective surgical techniques. There is also very little written on the topic of spasticity management after traumatic brain injury, especially in children. Most of the information we have is derived from stroke research. The focus of management strategies are largely medication use, physical therapy, and other physical rehabilitative strategies, with surgical management techniques used for long-term refractory cases only. With this manuscript, the authors aim to review our current understanding of the pathophysiology and management options, as well as prevention, of spasticity after traumatic brain injury in children.
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Affiliation(s)
- Johannes M N Enslin
- Paediatric Neurosurgery Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K Rohlwink
- Paediatric Neurosurgery Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,Division of Neurosurgery, University of Cape Town, Cape Town, South Africa.,Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Anthony Figaji
- Paediatric Neurosurgery Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
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65
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Persson CU, Holmegaard L, Redfors P, Jern C, Blomstrand C, Jood K. Increased muscle tone and contracture late after ischemic stroke. Brain Behav 2020; 10:e01509. [PMID: 31893564 PMCID: PMC7010575 DOI: 10.1002/brb3.1509] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 10/21/2019] [Accepted: 11/24/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Systematic studies on increased muscle tone and spasticity late after ischemic stroke, without any selection, are limited. Therefore, we aimed to determine the prevalence of increased muscle tone, classical spasticity and contracture and predictors of increased muscle tone seven years after stroke. METHODS Consecutive patients with acute ischemic stroke <70 years of age (n = 411) were recruited to the Sahlgrenska Academy Study on Ischemic Stroke. Symptoms at index stroke were assessed using the Scandinavian Stroke Scale. Seven years after stroke, survivors (n = 358) were invited for follow-up assessments, of whom 292 agreed to participate and 288 contributed data. Muscle tone according to the Modified Ashworth scale, classical spasticity, and contracture was assessed by a neurologist. The associations between increased muscle tone and characteristics at index stroke and recurrent strokes during follow-up were investigated using logistic regression analysis. RESULTS Increased muscle tone was recognized in 99 participants (34%): 94 (33%) in the upper limbs, and 72 (25%) in the lower limbs. Classical spasticity was found in 51 participants (18%) and contracture in 26 (9%). Age (odds ratio [OR] 1.03 [95% confidence interval [CI] 1.00-1.06]), arm paresis (OR 1.76 [95% CI 1.40-2.2]), aphasia (OR 1.68 [95% CI 1.12-2.51]), and facial palsy (OR 2.12 [95% CI 1.10-4.07]) were independent predictors of increased muscle tone. CONCLUSIONS One-third of patients with ischemic stroke before 70 years of age showed increased muscle tone at 7-year follow-up. Half of them also had classical spasticity. Age, arm paresis, aphasia, and facial palsy at index stroke were predictors of increased muscle tone poststroke.
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Affiliation(s)
- Carina U Persson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, Rehabilitation Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Physiotherapy, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Lukas Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christina Jern
- Department of Clinical Pathology and Genetics, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Stroke Centre West, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Blomstrand
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Stroke Centre West, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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66
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Teasell R, Salbach NM, Foley N, Mountain A, Cameron JI, Jong AD, Acerra NE, Bastasi D, Carter SL, Fung J, Halabi ML, Iruthayarajah J, Harris J, Kim E, Noland A, Pooyania S, Rochette A, Stack BD, Symcox E, Timpson D, Varghese S, Verrilli S, Gubitz G, Casaubon LK, Dowlatshahi D, Lindsay MP. Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update 2019. Int J Stroke 2020; 15:763-788. [PMID: 31983296 DOI: 10.1177/1747493019897843] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.
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Affiliation(s)
- Robert Teasell
- Stroke Rehabilitation Program, 60446Parkwood Hospital, London, Canada
- Western University, London, Canada
| | - Nancy M Salbach
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | | | - Anita Mountain
- Division of Physical Medicine and Rehabilitation, 3688Dalhousie University, Halifax, Canada
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Jill I Cameron
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
| | - Andrea de Jong
- 33484Heart and Stroke Foundation of Canada, Toronto, Canada
| | - Nicole E Acerra
- Neurosciences and Physical Therapy, Vancouver Coastal Health, Vancouver, Canada
| | - Diana Bastasi
- School of Physical and Occupational Therapy, 5620McGill University, Montréal, Canada
| | - Sherri L Carter
- Department of Psychology and Neuroscience, 3688Dalhousie University, Halifax, Canada
| | - Joyce Fung
- School of Physical and Occupational Therapy, 5620McGill University, Montréal, Canada
- Jewish Rehabilitation Hospital (CISSS-Laval) research site of CRIR, Montréal, Canada
| | - Mary-Lou Halabi
- Stroke Program, Edmonton Zone, Alberta Health Services, Edmonton, Canada
| | | | - Jocelyn Harris
- School of Rehabilitation Sciences, 3710McMaster University, Hamilton, Canada
| | - Esther Kim
- Department of Communication Sciences and Disorders, 3158University of Alberta, Edmonton, Canada
| | - Andrea Noland
- School of Audiology and Speech Sciences, University of British Columbia, Vancouver, Canada
| | - Sepideh Pooyania
- Physical Medicine and Rehabilitation, University of Manitoba, Winnipeg, Canada
| | - Annie Rochette
- School of Rehabilitation, University of Montreal, Montreal, Canada
| | | | - Erin Symcox
- Tertiary Neuro Rehabilitation, 26634Foothills Medical Centre, Calgary, Alberta
| | - Debbie Timpson
- Physical Medicine and Rehabilitation, 153197Pembroke Regional Hospital, Pembroke, Canada
| | - Suja Varghese
- Rehabilitation and Palliative Care Program, 102793Eastern Health, Newfoundland and Labrador, St. John's, Canada
| | - Sue Verrilli
- Northeastern Ontario Stroke Network, Sudbury, Canada
| | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre Stroke Program, Halifax, Canada
| | | | - Dar Dowlatshahi
- Faculty of Medicine, 6363University of Ottawa, Ottawa, Canada
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Afzal T, Rymer WZ, Suresh NL. A Tendon Indentation Method to Quantify Velocity-Dependent Reflex Responses after Hemispheric Stroke. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:5221-5224. [PMID: 31947035 DOI: 10.1109/embc.2019.8857639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stretch reflex responses in passive muscle can be utilized to assess spasticity in chronic stroke survivors. In this study, we present a different method of eliciting the reflex response by imposing tendon indentation using a linear motor. Specifically, we test a "Ramp-and-hold" protocol, utilizing a linear motor controlled by a position-controlled feedback loop (Linmot, Inc), to indent the biceps brachii distal tendon at different velocities. The protocol was tested on the affected arm of three stroke subjects. We also utilized a tendon indentation combined with tendon-tapping method to quantify the reflex threshold. Our results indicate that the reflex response was elicited at velocities equal to or above 50 mm/s in 2/3 subjects. No reflex response was detected in one subject. All subjects showed a distinct reflex threshold using the indentation/tapping method. Furthermore, the presence of a reflex response during tendon-tapping was not necessarily accompanied by the elicitation of a reflex response during the ramp-and-hold. However, our data suggests that the indentation threshold during tapping is correlated to the presence of a reflex response at the velocities tested during the ramp-and-hold. Though more time consuming, tendon indentation using ramp-and-hold could provide greater resolution of the reflex response to quantify spasticity than the current clinically employed ballistic tapping method using a reflex hammer.
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68
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Freire B, Abou L, Dias CP. Equinovarus foot in stroke survivors with spasticity: a narrative review of muscle–tendon morphology and force production adaptation. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2020. [DOI: 10.12968/ijtr.2017.0124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims Spastic paresis is the most common motor disorder in stroke survivors and can cause various types of muscle overactivity. This can lead to the development of spastic equinovarus foot, producing an inadequate base of support that limits locomotion and weight transfers. Physical therapists require better knowledge of the effects of spastic equinovarus foot in order to administer effective clinical treatment. Therefore, the aim of the present review was to describe changes in the muscle morphology and force production of stroke survivors with spastic equinovarus foot in relation to gait performance. Methods A narrative review of research into the effects of spastic paresis and equinovarus foot in stroke survivors was undertaken. Results There were a total of 20 identified studies that observed muscle-tendon morphology and force production in stroke survivors. All studies included in the present review reported several changes in muscle and tendon biomechanical properties as results of the spastic muscle overactivity. Conclusions Stroke survivors with spastic equinovarus foot experience muscle and tendon morphology that result in decreased force production, muscle power and gait performance.
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Affiliation(s)
- Bruno Freire
- University of State of Santa Catarina, Florianópolis, Brazil
| | - Libak Abou
- University of Illinois, Urbana-Champaign, USA
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69
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Cao N, Nguyen B, Li S, Lamba R, Hafner R, Li S. An overview of acupuncture in stroke recovery: A narrative review. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2020. [DOI: 10.4103/jisprm.jisprm_19_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Amatya B, Cofré Lizama LE, Elmalik A, Bastani A, Galea MP, Khan F. Multidimensional evaluation of changes in limb function following botulinum toxin injection in persons with stroke. NeuroRehabilitation 2019; 45:67-78. [PMID: 31403954 DOI: 10.3233/nre-192722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are limited evidence of instrumented measures of gait and balance to determine the functional effects of botulinum toxin injections (BoNT-A) in spasticity after stroke. OBJECTIVE To evaluate the functional changes in gait and balance following upper limb and lower limb BoNT-A in persons with stroke. METHODS A pre-post prospective study of 35 stroke patients with upper and/or lower limb spasticity after focal treatment with BoNT-A. Assessments were at baseline (T0), 6-weeks (T1) and 12-weeks (T2), using validated subjective and objective physical activity measures. RESULTS After BoNT-A injections, significant improvements in most measures of impairments, activity and participation domains were found at T1 (p < 0.05, effect sizes (r) = 0.5-0.9). There was a significant increase in low intensity physical activity (at T1) and sedentary time reductions at both follow-up periods. Instrumented gait/balance measures showed a significant increase in cadence and turn velocity, but no changes in sway measures were found using posturography. Improvements in most outcome measures were maintained at 12-weeks. CONCLUSION BONT-A improved scores in most clinical measures but only in some of the objective gait/balance and physical activity measures. Further robust studies should utilize a larger sample size to better determine the benefits of BoNT-A for stroke-related spasticity.
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Affiliation(s)
- B Amatya
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
| | - L E Cofré Lizama
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
| | - A Elmalik
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
| | - A Bastani
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
| | - M P Galea
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
| | - F Khan
- Department of Rehabilitation Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.,Australian Rehabilitation Research Centre, VIC, Australia
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71
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Alashram AR, Padua E, Romagnoli C, Annino G. Effectiveness of focal muscle vibration on hemiplegic upper extremity spasticity in individuals with stroke: A systematic review. NeuroRehabilitation 2019; 45:471-481. [DOI: 10.3233/nre-192863] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Anas R. Alashram
- School of Neuroscience, Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, Rome, Italy
- Department of Medicine Systems, University of Rome “Tor Vergata”, Rome, Italy
| | - Elvira Padua
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
| | - Cristian Romagnoli
- Science and Culture of Well-being and Lifestyle, Alma Mater University, Bologna, Italy
| | - Giuseppe Annino
- Department of Medicine Systems, University of Rome “Tor Vergata”, Rome, Italy
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72
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Afzal T, Chardon MK, Rymer WZ, Suresh NL. Stretch reflex excitability in contralateral limbs of stroke survivors is higher than in matched controls. J Neuroeng Rehabil 2019; 16:154. [PMID: 31806032 PMCID: PMC6896352 DOI: 10.1186/s12984-019-0623-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/13/2019] [Indexed: 11/10/2022] Open
Abstract
Background Spasticity, characterized by hyperreflexia, is a motor impairment that can arise following a hemispheric stroke. While the neural mechanisms underlying spasticity in chronic stroke survivors are unknown, one probable cause of hyperreflexia is increased motoneuron (MN) excitability. Potential sources of increased spinal MN excitability after a stroke include increased vestibulospinal (VS) and/or reticulospinal (RS) drive. Spasticity, as clinically assessed in stroke survivors, is highly lateralized, thus RS contributions to stroke-induced spasticity are more difficult to reconcile, as RS nuclei routinely project bilaterally to the spinal cord. Yet studies in stroke survivors suggest that there may also be changes in neuromodulation at the spinal level, indicative of RS tract influence. We hypothesize that after hemispheric stroke, alterations in the excitability of the RS nuclei affect both sides of the spinal cord, and thereby contribute to increased MN excitability on both paretic/spastic and contralateral sides of stroke survivors, as compared to neurologically intact subjects. Methods We estimated stretch reflex thresholds of the biceps brachii (BB) muscle using a position-feedback controlled linear motor to progressively indent the BB distal tendon in both spastic and contralateral limbs of hemispheric stroke survivors and in age-matched intact subjects. Results Our previously reported results show a significant difference between reflex thresholds of spastic and contralateral limbs of stroke survivors recorded from BB-medial (p < 0.005) and BB-lateral (p < 0.001). For this study, we report that there is also a significant difference between the reflex thresholds in the contralateral limb of stroke subjects and the dominant arm of intact subjects, again measured from both BB-medial (p < 0.05) and BB-lateral (p < 0.05). Conclusion The reduction in stretch reflex thresholds in the contralateral limb of stroke survivors, based here on comparisons with thresholds of intact subjects, suggests an increased MN excitability on contralateral sides of stroke survivors as compared to intact subjects. This in turn supports our contention that RS tract activation, which has bilateral descending influences, is at least partially responsible for increased stretch reflex excitability, post-stroke, as both contralateral and affected sides show increased MN excitability as compared to intact subjects. Still, spasticity, presently diagnosed only on the affected side, with increased MN excitability on the affected side as compared to the contralateral side (our previous study), may be due to a different strongly lateralized pathway, such as the VS tract, which has not been directly tested here. Currently available clinical methods of spasticity assessment, such as the Modified Ashworth Scale, lack the resolution to quantify this phenomenon of a bilateral increase in MN excitability.
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Affiliation(s)
- Taimoor Afzal
- Department of Physical Medicine and Rehabilitation, Northwestern University, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA. .,Single Motor Unit Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA.
| | | | - William Z Rymer
- Department of Physical Medicine and Rehabilitation, Northwestern University, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA.,Single Motor Unit Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA
| | - Nina L Suresh
- Department of Physical Medicine and Rehabilitation, Northwestern University, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA.,Single Motor Unit Lab, Shirley Ryan AbilityLab, 355 E. Erie Street, Floor 21, Chicago, IL, 60611, USA
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Hara T, Momosaki R, Niimi M, Yamada N, Hara H, Abo M. Botulinum Toxin Therapy Combined with Rehabilitation for Stroke: A Systematic Review of Effect on Motor Function. Toxins (Basel) 2019; 11:toxins11120707. [PMID: 31817426 PMCID: PMC6950173 DOI: 10.3390/toxins11120707] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/16/2022] Open
Abstract
Aim: The purpose of this study was to examine the effectiveness of botulinum toxin A (BoNT-A) therapy combined with rehabilitation on motor function in post-stroke patients. Methods: The following sources up to December 31, 2018, were searched from inception for articles in English: Pubmed, Scopus, CINAHL, Embase, PsycINFO, and CENTRAL. Trials using injections of BoNT-A for upper and lower limb rehabilitation were examined. We excluded studies that were not performed for rehabilitation or were not evaluated for motor function. Results: Twenty-six studies were included. In addition to rehabilitation, nine studies used adjuvant treatment to improve spasticity or improve motor function. In the upper limbs, two of 14 articles indicated that significant improvement in upper limb motor function was observed compared to the control group. In the lower limbs, seven of 14 articles indicated that significant improvement in lower limb motor function was observed compared to the control group. Conclusions: The effect of combined with rehabilitation is limited after stroke, and there is not sufficient evidence, but results suggest that BoNT-A may help to improve motor function. In future studies, the establishment of optimal rehabilitation and evaluation times of BoNT-A treatment will be necessary for improving motor function and spasticity.
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Affiliation(s)
- Takatoshi Hara
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
- Correspondence: ; Tel.: +81-3-3433-1111; Fax: +81-3-3431-1206
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa 213-8507, Japan
| | - Masachika Niimi
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Naoki Yamada
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Hiroyoshi Hara
- Rehabilitation Center, Ainomiyako Neurosurgery Hospital, Osaka 538-0044, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
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Neusser S, Kreuzenbeck C, Pahmeier K, Lux B, Wilke A, Wasem J, Neumann A. Budget impact of botulinum toxin treatment for spasticity after stroke — a German perspective. J Public Health (Oxf) 2019. [DOI: 10.1007/s10389-019-01161-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract
Aim
Botulinum toxin agents can improve the quality of life of patients with post-stroke upper limb spasticity (ULS) and are recommended by international and German guidelines. However, health-services research indicates an underuse of botulinum toxin agents in this patient group. The study aims to clarify the budget impact of treatment with botulinum toxin agents according to the guidelines for all eligible patients with ULS in Germany compared to usual care.
Methods
The budgetary impact for the statutory health insurance system was estimated by calculating a Markov cohort model with a timeframe of 5 years comparing three treatment options. Four health states were included. The base-case analysis compares standard doses of two botulinum toxin agents to usual care. The model accounts for direct medical costs. Sensitivity analyses vary doses of botulinum toxin agents and prevalence of spasticity after stroke.
Results
In the base case, both botulinum toxin agents lead to increased costs compared to usual care. Treatment with Dysport® (cumulative costs for the 5-year period: €280,321,317) is less expensive than the treatment with Xeomin® (€377,511,529). Cumulative costs over 5 years in usual care are €61,306,062.
Conclusion
The botulinum toxin therapy is associated with additional costs, but an increased use of botulinum toxin would be consistent with guideline-based therapy. In particular, it has to be considered that spasticity as a chronic condition is accompanied by a relevant loss of quality of life. Thus, considering only the therapy costs may not be sufficient for making final therapeutic decisions.
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75
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Wallace AC, Talelli P, Crook L, Austin D, Farrell R, Hoad D, O'Keeffe AG, Marsden JF, Fitzpatrick R, Greenwood R, Rothwell JC, Werring DJ. Exploratory Randomized Double-Blind Placebo-Controlled Trial of Botulinum Therapy on Grasp Release After Stroke (PrOMBiS). Neurorehabil Neural Repair 2019; 34:51-60. [PMID: 31747825 DOI: 10.1177/1545968319887682] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. OnabotulinumtoxinA injections improve upper-limb spasticity after stroke, but their effect on arm function remains uncertain. Objective. To determine whether a single treatment with onabotulinumtoxinA injections combined with upper-limb physiotherapy improves grasp release compared with physiotherapy alone after stroke. Methods. A total of 28 patients, at least 1 month poststroke, were randomized to receive either onabotulinumtoxinA or placebo injections to the affected upper limb followed by standardized upper-limb physiotherapy (10 sessions over 4 weeks). The primary outcome was time to release grasp during a functionally relevant standardized task. Secondary outcomes included measures of wrist and finger spasticity and strength using a customized servomotor, clinical assessments of stiffness (modified Ashworth Scale), arm function (Action Research Arm Test [ARAT], Nine Hole Peg Test), arm use (Arm Measure of Activity), Goal Attainment Scale, and quality of life (EQ5D). Results. There was no significant difference between treatment groups in grasp release time 5 weeks post injection (placebo median = 3.0 s, treatment median = 2.0 s; t(24) = 1.20; P = .24; treatment effect = -0.44, 95% CI = -1.19 to 0.31). None of the secondary measures passed significance after correcting for multiple comparisons. Both groups achieved their treatment goals (placebo = 65%; treatment = 71%), and made improvements on the ARAT (placebo +3, treatment +5) and in active wrist extension (placebo +9°, treatment +11°). Conclusions. In this group of stroke patients with mild to moderate spastic hemiparesis, a single treatment with onabotulinumtoxinA did not augment the improvements seen in grasp release time after a standardized upper-limb physiotherapy program.
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Affiliation(s)
| | | | - Lucinda Crook
- UCL Institute of Neurology, Queen Square, London, UK
| | - Duncan Austin
- UCL Institute of Neurology, Queen Square, London, UK
| | - Rachel Farrell
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Damon Hoad
- UCL Institute of Neurology, Queen Square, London, UK
| | | | | | | | - Richard Greenwood
- National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | | | - David J Werring
- UCL Institute of Neurology, Queen Square, London, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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76
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López de Munain L, Valls-Solé J, Garcia Pascual I, Maisonobe P. Botulinum Toxin Type A Improves Function According to Goal Attainment in Adults with Poststroke Lower Limb Spasticity in Real Life Practice. Eur Neurol 2019; 82:1-8. [PMID: 31726452 DOI: 10.1159/000503172] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/03/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Botulinum toxin type A (BoNT-A) is an effective and well-tolerated treatment for adult lower limb spasticity. However, data are inadequate to determine BoNT-A efficacy for active function. This study evaluated functional goal achievement (measured by goal attainment scaling [GAS]) following lower limb BoNT-A injection in clinical practice. METHODS Phase 4, postmarketing, multicenter, prospective, observational study (NCT01444794) in adults with poststroke lower limb spasticity receiving one BoNT-A injection cycle. Assessments were at baseline (pretreatment), 1 month ±7 days (visit 1), and 3-5 months posttreatment (visit 2). Primary outcome measure was GAS; additional assessments included Modified Ashworth Scale, Demeurisse Motricity Index, 10-meter walk test, and Disability Assessment Scale. RESULTS Of 100 enrolled patients, 94 completed the study. Most common primary treatment goals at baseline were improving mobility (57.5%) and positioning (18.1%). At visit 2, 88.3% achieved their primary goal; 87.0% (n = 47/54) for mobility, and 100.0% (n = 17/17) for positioning. In total, 79.1% of patients achieved their secondary goals. Two factors were predictive of primary goal achievement: time since stroke onset (OR 0.907; 95% CI 0.827-0.995; p = 0.038); and absence of stiff knee spasticity pattern (OR 0.228; 95% CI 0.057-0.911; p = 0.036). All functional scales showed improvements; walking speed (mean [SD]) improved by 0.06 (0.13) and 0.05 (0.20) m/s at visits 1 and 2, respectively. CONCLUSIONS BoNT-A injection for lower limb spasticity led to high goal achievement rates in patient-centered GAS evaluation and functional and symptomatic improvements. BoNT-A may therefore deliver clinically meaningful functional improvements in real-life practice.
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Affiliation(s)
- Lourdes López de Munain
- Department of Rehabilitation, Hospital Universitario Marqués de Valdecilla, Santander, Spain,
| | - Josep Valls-Solé
- Department of Neurology, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
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77
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Sunnerhagen K, Opheim A, Alt Murphy M. Onset, time course and prediction of spasticity after stroke or traumatic brain injury. Ann Phys Rehabil Med 2019; 62:431-434. [DOI: 10.1016/j.rehab.2018.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
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78
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Shin H, Hu X. Multichannel Nerve Stimulation for Diverse Activation of Finger Flexors. IEEE Trans Neural Syst Rehabil Eng 2019; 27:2361-2368. [PMID: 31634137 DOI: 10.1109/tnsre.2019.2947785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Neuromuscular electrical stimulation (NMES) is a common approach to restore muscle strength of individuals with a neurological injury but restoring hand dexterity is still a challenge. This study sought to quantify the diversity of finger movements elicited by a multichannel nerve stimulation technique. METHODS A 2 × 8 stimulation grid, placed on the upper arm along the ulnar and median nerves, was used to activate different finger flexors by automatically switching between randomized bipolar electrodes. The forces from each individual finger as well as the high-density electromyogram (HDEMG) of the intrinsic and extrinsic flexors were recorded. The elicited finger forces were categorized using hierarchical clustering, and the 2D correlation of the spatial patterns of muscle activation was also calculated. RESULTS A wide range of movement patterns were identified, including multi-finger and single-digit movements. Additionally, a number of electrode pairs elicited similar finger movements. The muscle activation patterns showed similar and distinct spatial patterns, signifying activation redundancy. CONCLUSION These results revealed the diversity of elicitable finger movements and muscle activations. The system redundancy can be explored to compensate for system instability due to fatigue or electrode shift. The outcomes can also enable the development of an automatic calibration of the stimulation.
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79
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Menon RG, Raghavan P, Regatte RR. Quantifying muscle glycosaminoglycan levels in patients with post-stroke muscle stiffness using T 1ρ MRI. Sci Rep 2019; 9:14513. [PMID: 31601831 PMCID: PMC6787087 DOI: 10.1038/s41598-019-50715-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022] Open
Abstract
The purpose of this study was to provide imaging evidence of increased glycosaminoglycan (GAG) content in patients with post-stroke muscle stiffness; and to determine the effect of hyaluronidase treatment on intramuscular GAG content. In this prospective study, we used 3D-T1ρ (T1rho) magnetic resonance (MR) mapping of the upper arm muscles to quantify GAG content in patients with post-stroke muscle stiffness before and after hyaluronidase injection treatment. For this study, healthy controls (n = 5), and patients with post-stroke muscle stiffness (n = 5) were recruited (March 2017-April 2018). T1ρ MR imaging and Dixon water-fat MR imaging of the affected upper arms were performed before and after off-label treatment with hyaluronidase injections. T1ρ mapping was done using a three-parameter non-linear mono-exponential fit. Wilcoxon Mann-Whitney test was used to compare patients' vs controls and pre- vs post-treatment conditions. The T1ρ values in the biceps were significantly higher in patients before treatment (34.04 ± 4.39 ms) compared with controls (26.70 ± 0.54 ms; P = 0.006). Significant improvement was seen in the biceps of patients before (35.48 ± 3.38 ms) and after treatment (29.45 ± 1.23 ms; P = 0.077). Dixon water-fat distribution was not significantly different in the patients compared to the controls (biceps P = 0.063; triceps P = 0.190). These results suggest that T1ρ mapping can be used to quantify GAG content in the muscles of patients with post-stroke muscle stiffness, and that muscle hyaluronan content is increased in stiff muscles compared with controls, providing imaging corroboration for the hyaluronan hypothesis of muscle stiffness.
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Affiliation(s)
- Rajiv G Menon
- Bernard and Irene Schwartz Center for Biomedical Imaging, New York University School of Medicine, New York, NY, USA.
| | - Preeti Raghavan
- Depts. of Physical Medicine and Rehabilitation and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Rusk Rehabilitation, New York University School of Medicine, New York, NY, USA
| | - Ravinder R Regatte
- Bernard and Irene Schwartz Center for Biomedical Imaging, New York University School of Medicine, New York, NY, USA
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80
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Measuring muscle tone with isokinetic dynamometer technique in stroke patients. BIOMEDICAL HUMAN KINETICS 2019. [DOI: 10.2478/bhk-2019-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Summary
Study aim: Increased muscle tone, a common consequence of stroke, has neural and non-neural components. Spasticity is related to the neural component. Non-neural resistance arises from passive stiffness. This study was designed to assess the feasibility of using isokinetic dynamometry to evaluate wrist flexor muscle spasticity in stroke patients.
Materials and methods: Twenty-six patients with hemiplegia in the subacute phase of stroke participated in this study. An isokinetic dynamometer was used to stretch wrist flexor muscles at four velocities of 5, 60, 120 and 180°/s on both the paretic and non-paretic sides. Peak torque at the lowest speed (5°/s) and reflex torque at the three higher speeds were quantified. Peak torque at the lowest speed was attributed to the non-neural component of muscle tone, and was subtracted from the torque response at higher velocities to estimate reflex torque (spasticity). Data from the two sides were compared.
Results: There was no significant difference in peak torque between the paretic (2.47 ± 0.22 N·m) and non-paretic side (2.41 ± 0.28 N·m) at the lowest velocity of 5°/s (p=0.408). However, compared to the non-paretic side, the paretic side showed higher reflex torque (p<0001), and reflex torque increased rapidly with increasing velocity (p < 0.05).
Conclusion: The isokinetic dynamometer distinguished spasticity from the non-neural component and showed higher reflex torque on the paretic side compared to the non-paretic side. This instrument is potentially useful to assess the efficacy of therapeutic interventions aimed at modifying spasticity.
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81
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Thielman G, Yourey L. Ultrasound imaging of upper extremity spastic muscle post-stroke and the correlation with function: A pilot study. NeuroRehabilitation 2019; 45:213-220. [PMID: 31498134 DOI: 10.3233/nre-192742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND With increased practice of real-time ultrasound imaging in the physical therapy profession, it is essential to evaluate the utility of its use post stroke. OBJECTIVE Evaluate relationship of spastic brachialis muscle architectural parameters with clinical measures of upper extremity function and spasticity. METHODS Eleven post stroke individuals with spasticity of the upper limb had their brachialis muscle pennation angle and fascicle length measured in the affected and unaffected upper arm, at rest. Involved side upper extremity Fugl-Meyer, Modified Ashworth Scale, and grip strength were collected and compared to muscle architectural parameters of affected and unaffected brachialis muscles. RESULTS Affected side brachialis pennation angle was significantly greater than the unaffected side, and affected fascile length was significantly shorter than the unaffected side. Function levels were found to be significantly higher in those with greater fascile lengths and lower pennation angles. Higher Fugl-Meyer scores of the affected upper extremity were inversely correlated with lower Modified Ashworth Scale scores. CONCLUSIONS An objective method of quantifying spasticity can assist in determining if functional gains made post stroke are due to compensations in movement, or due to physiological changes. Ultrasound imaging may be used as an alternative to the Modified Ashworth score to quantify muscular parameters in spastic muscles post stroke.
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Affiliation(s)
| | - Lucas Yourey
- University of the Sciences, Philadelphia, PA, USA
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82
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Gomes ALS, Mello FFD, Cocicov Neto J, Benedeti MC, Modolo LFM, Riberto M. Can the positions of the spastic upper limb in stroke survivors help muscle choice for botulinum toxin injections? ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:568-573. [PMID: 31508683 DOI: 10.1590/0004-282x20190087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/05/2019] [Indexed: 11/22/2022]
Abstract
Motor impairments in stroke survivors are prevalent and contribute to dependence in daily activities, pain and overall disability, which can further upper-limb disability. Treatment with botulinum toxin A (BoNT-A) is indicated for focal spasticity and requires knowledge of biomechanics and anatomy to best select muscles to be injected in the limb. OBJECTIVE We aimed to describe the frequency of posture patterns in a Brazilian sample of stroke survivors and correlate them with recommendations of muscle selection for treatment with BoNT-A. METHODS Fifty stroke patients with spastic upper limbs scheduled for neuromuscular block were photographed and physically examined, to be classified by three independent evaluators according to Hefter's classification. Muscles that were injected with BoNT-A by their routine doctors were retrieved from medical charts. RESULTS Pattern III and IV were the most common (64.7%, 21.6%). We further subclassified pattern III according to the rotation of the shoulder, which effectively interfered in muscle choice. The muscles most frequently treated were shoulder adductors and internal rotators, elbow flexors and extensors, in forearm, the pronator teres and finger and wrist flexors, and, in the hand the adductor pollicis. CONCLUSION Frequencies of upper-limb postures differed from previous reports. Other clinical features, besides spasticity, interfered with muscle choice for BoNT-A injection, which only partially followed the recommendations in the literature.
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Affiliation(s)
- André Luiz Salcedo Gomes
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
| | - Francisco Falleiros de Mello
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
| | - Jorge Cocicov Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
| | - Marcelo Causin Benedeti
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
| | - Luis Felipe Miras Modolo
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
| | - Marcelo Riberto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Ribeirão Preto SP, Brasil
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83
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Ashford SA, Siegert RJ, Williams H, Nair A, Orridge S, Turner-Stokes L. Psychometric evaluation of the leg activity measure (LegA) for outcome measurement in people with brain injury and spasticity. Disabil Rehabil 2019; 43:976-987. [PMID: 31328963 DOI: 10.1080/09638288.2019.1643933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study is to evaluate the properties of the Leg Activity measure according to COnsensus-based Standards for the selection of health Measurement INstruments. METHOD Participants were assessed at baseline, one day, 6 weeks and 12 weeks, following treatment for leg spasticity with botulinum toxin and physical interventions. RESULTS In stage 1, 64 participants were recruited to evaluate the initial psychometric properties of Leg Activity measure. In stage 2, 100 additional participants were recruited, to evaluate the scaling properties. Total sample of 164 participants was used. Construct validity was supported for "passive function", "active function" and "impact on quality of life". Cronbach's alpha was 0.86, 0.97 and 0.87 respectively for the scales. Item level test-retest agreement ranged from 91-97% (Kappa 0.75-0.95). Following treatment for spasticity (n = 64), the Leg Activity measure "passive function" and "impact on life" scales were responsive to change. Principal components analysis confirmed the constructs and a unidimensional Rasch Partial Credit Model was subsequently established for each scale. Transformation to an interval scale was achieved. Using the ordinal-to-interval conversion tables, parametric statistical analysis may be used. CONCLUSION The study provides support for the Leg Activity measure being valid, reliable and responsive.Implications for rehabilitationThe Leg Activity measure is the only published self-report measure in the current literature that addresses passive and active function as well as impact on quality of life, of the paretic leg in a comprehensive manner.The initial evaluation of Leg Activity measure psychometric properties, in relation to the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Medical Outcomes Trust Quality Criteria, supports its measurement properties for clinical and research use.The Leg Activity measure as a valid, reliable and responsive tool for the evaluation of treatment in leg spasticity including condition specific (spasticity) quality-of-life.
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Affiliation(s)
- Stephen A Ashford
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.,Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Centre for Nursing and Midwifery led Research, University College London Hospital, London, UK
| | - Richard J Siegert
- Department of Psychology, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand
| | - Heather Williams
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK
| | - Ajoy Nair
- Alderbourne Rehabilitation Unit, Hillingdon Hospital, London, UK
| | | | - Lynne Turner-Stokes
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.,Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Protásio de Melo L, da Silva Costa V, Cunha da Silveira JC, Albuquerque Clementino TC. Investigation of the effects of mirror therapy on the spasticity, motor function and functionality of impaired upper limbs in chronic stroke patients. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2019. [DOI: 10.12968/ijtr.2017.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims Strokes lead to different levels of disability. During the chronic stage, hemiparesis, spasticity and motor deficits may cause loss of functional independence. Mirror therapy aims to reduce deficits and increase functional recovery of the impaired upper limb. This study aimed to evaluate the effects of mirror therapy on upper limb spasticity and motor function, as well as its impact on functional independence in chronic hemiparetic patients. Methods In this quasi-experimental study, eight chronic hemiparetic patients (age 55.5 ± 10.8 years) were assessed to determine their degree of spasticity (Modified Ashworth Scale), level of upper limb motor function (Fugl-Meyer Assessment) and functionality (Functional Independence Measure). All participants received 12 sessions of mirror therapy delivered three times per week, over a period of 4 weeks. Participants were re-evaluated post-intervention and these results were compared to their pre-intervention scores to determine the impact of mirror therapy. Results A decrease in spasticity was observed, with significant improvements in shoulder extensors (P=0.033) and a significant increase in motor function (P=0.002). The therapeutic protocol adopted did not have a significant effect on functional independence (P=0.105). Conclusions Mirror therapy led to improvements in upper limb spasticity and motor function in chronic hemiparetic stroke patients. No effects on functional independence were observed. Further research with a larger number of patients is needed to provide more robust evidence of the benefits of mirror therapy in chronic hemiparetic stroke patients.
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Affiliation(s)
- Luciana Protásio de Melo
- Physiotherapy Professor and Researcher, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Valton da Silva Costa
- Research student, Postgraduate Programme in Neuroengineering, Faculty of Educational Excellence of Rio Grande do Norte, Natal, Brazil
| | - Júlio César Cunha da Silveira
- Physiotherapist, Postgraduate Programme in Neuroengineering, Faculty of Educational Excellence of Rio Grande do Norte, Natal, Brazil
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Association Between Spasticity and Functional Impairments During the First Year After Stroke in Korea: The KOSCO Study. Am J Phys Med Rehabil 2019; 97:557-564. [PMID: 29509548 DOI: 10.1097/phm.0000000000000916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the correlation between spasticity severity and functional outcomes during the first year after stroke. DESIGN The Korean Stroke Cohort for Functioning and Rehabilitation is a large, multicenter, prospective cohort study of all patients with acute first-ever stroke admitted to participating hospitals in nine Korean areas. To investigate the correlation between spasticity severity and functional status measured by using the Institutes of Health Stroke Scale (NIHSS), Modified Barthel Index (MBI), Functional Independence Measurement (FIM), Fugl-Meyer Assessment (FMA), Functional Ambulatory Category (FAC), modified Rankin scale (mRS), and American Speech-Language Hearing Association National Outcome Measurement System Swallowing Scale (ASHA-NOMS), data were analyzed at 3, 6, and 12 mos after the occurrence of stroke. RESULTS A total of 7359 stroke patients, 3056 were finally included. Prevalence rates of spasticity in patients after stroke were 6.8% at 3 mos, 6.9% at 6 mos, and 7.6% at 12 mos. The scores of mRS and NIHSS were higher and those of K-MBI, FIM, FMA, and ASHA-NOMS were lower in more severe spastic patients, indicating poorer functional outcomes (P < 0.05). CONCLUSIONS This study demonstrated the coexistence of spasticity and poor functional outcome during the first year after first-ever stroke patients.
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Cai Y, Zhang CS, Liu S, Wen Z, Zhang AL, Guo X, Xue CC, Lu C. Add-On Effects of Chinese Herbal Medicine for Post-Stroke Spasticity: A Systematic Review and Meta-Analysis. Front Pharmacol 2019; 10:734. [PMID: 31316387 PMCID: PMC6610255 DOI: 10.3389/fphar.2019.00734] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/07/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Treatment for post-stroke spasticity (PSS) remains a major challenge in clinical practice. Chinese herbal medicine (CHM) is often administered to assist in routine care (RC) in the treatment of PSS, with increasing numbers of clinical research and preclinical studies suggesting that it has potential benefits. Therefore, we conducted a systematic review and meta-analysis to evaluate the add-on effects and safety of CHM for PSS. Methods: Five English and four Chinese databases were searched from their respective inception to 28 February 2018. We included randomized controlled trials that evaluated the add-on effects of CHM for PSS, based on changes in the scores of the (Modified) Ashworth Scale (AS or MAS), Fugl-Meyer Assessment of Sensorimotor Recovery (FMA), and Barthel Index (BI). Results: Thirty-five trials involving 2,457 patients were included. For upper-limb AS or MAS, the estimated add-on effects of CHM to RC were significantly better when using oral (SMD -1.79, 95% CI: -3.00 to -0.57) or topical CHM (SMD -1.06, 95% CI: -1.40 to -0.72). For lower-limb AS or MAS, significant add-on benefits to RC were also detected (SMD -1.01, 95% CI: -1.43 to -0.59 and SMD -1.16, 95% CI: -1.83 to -0.49) using oral and topical CHM, respectively. For FMA and BI, better results were detected when adding CHM to RC, except for the subgroup of oral CHM for upper-limb FMA. Ten of the 35 included studies reported safety information, with two of them mentioning two mild adverse events. Conclusions: Noting the quality concerns of the included trials, this review suggests that CHM appears to be a well-tolerated therapy for patients with PSS, and the potential add-on effects of CHM in reducing spasticity and improving the daily activities of patients with PSS require further rigorous assessment.
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Affiliation(s)
- Yiyi Cai
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Claire Shuiqing Zhang
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Shaonan Liu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Zehuai Wen
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Anthony Lin Zhang
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Xinfeng Guo
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Charlie Changli Xue
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Chuanjian Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), the Second Clinical College of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.,China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
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OnabotulinumtoxinA Reduces Temporal Pain Processing at Spinal Level in Patients with Lower Limb Spasticity. Toxins (Basel) 2019; 11:toxins11060359. [PMID: 31226803 PMCID: PMC6628414 DOI: 10.3390/toxins11060359] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 05/20/2019] [Accepted: 06/18/2019] [Indexed: 11/17/2022] Open
Abstract
Spasticity is a muscle tone disorder associated with different neurological conditions. Spasticity could be associated with pain, high disability, poor functional recovery, and reduced quality of life. Botulinum neurotoxin type A (BoNT-A) is considered a first-line treatment for spasticity and, more recently, it also represents a therapeutic option for various chronic pain conditions. In this open label study, we aim to evaluate the effect of the BoNT-A on the spinal nociception in patients affected by spasticity of the lower limbs with associated pain with predominantly neuropathic features. Ten patients with stroke, 10 with multiple sclerosis and 5 with spinal cord injury were enrolled in the study. They were tested with clinical scales (neuropathic pain scale inventory (NPSI), numerical rating scale (NRS), modified Ashworth scale (MAS) and with the nociceptive withdrawal reflex at lower limbs to explore the spinal temporal summation threshold at baseline and 30 day after BoNT-A injection. OnabotulinumtoxinA (50 to 200 units per site) was injected in the lower limb muscles according to the distribution of spasticity. No significant differences were found at baseline for neurophysiological features across groups. After the BoNT-A injection, we recorded a significant reduction in MAS and NRS scores. Regarding the neurophysiological parameters, we described a significant increase in the temporal summation threshold after the BoNT-A injection. Our data supports the hypothesis that peripherally injected OnabotulinumtoxinA modulates the excitability of spinal cord nociceptive pathways. This activity may take place irrespective of the effect of the drug on spasticity.
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External Robotic Arm vs. Upper Limb Exoskeleton: What Do Potential Users Need? APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9122471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Robotic devices that practically assist activities of daily living (ADL) are scarce. The aim of this study was to investigate practical demands of potential users of external robotic arms and upper limb exoskeletons for assistance in ADL. A survey was performed in rehabilitation clinics in individuals with functional impairments in the upper extremity, divided into unilateral (UIG, n = 24) and bilateral impairment groups (BIG, n = 24). Descriptive analyses were performed for current dependency, objective importance, and subjective necessity of the 18 ADLs by using a 5-point Likert scale. Overall, handling foods, dressing, and moving close items were highly necessary functions for both robot types. The UIG demonstrated a high demand for self-exercise using exoskeletons, whereas one-hand ADLs showed low necessity. In the UIG, the exoskeleton had significantly higher demands than the external robotic arm in washing face (p = 0.005) and brushing teeth (p = 0.007). The subjects in the BIG replied that cleaning desks and eating are highly necessary abilities for the external robotic arm; and transfer and wheelchair control, for exoskeletons. In the BIG, the exoskeleton showed significantly higher necessity than the external robotic arms in dressing (p = 0.010), making phone calls (p = 0.026), using a smartphone (p = 0.011), and writing (p = 0.005). The practical demands of potential users were affected by laterality and robot type. Further robot developments should involve essential functions based on the survey results to meet end-user needs.
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89
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Shorter AL, Finucane S, Rouse EJ. Ankle Mechanical Impedance During Waling in Chronic Stroke: Preliminary Results. IEEE Int Conf Rehabil Robot 2019; 2019:246-251. [PMID: 31374637 PMCID: PMC6924171 DOI: 10.1109/icorr.2019.8779436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Dynamic joint mechanics, collectively known as mechanical impedance, are often altered following upper motoneuron disease, which can hinder mobility for these individuals. Typically, assessments of altered limb mechanics are obtained while the patient is at rest, which differs from the dynamic conditions of mobility. The purpose of this study was to quantify ankle impedance during walking in individuals post-stroke, determine differences from the healthy population, and assess the relationship between impedance impairment and clinical outcome measures. Preliminary data were collected in four individuals post-stroke. Displacement perturbations were applied to the ankle during stance phase, and least-squares system identification was performed to estimate ankle impedance. In comparison to the healthy population, the paretic ankle showed reduced variation of stiffness during mid-stance of walking, and damping estimates during early and mid-stance were increased. Clinical measures obtained during dynamic tasks showed strong correlation with changes to the stiffness component of impedance, while clinical measures obtained passively were not correlated to stiffness. Impairment in ankle damping was not correlated with any of the measures tested. This work provides novel, preliminary insight into paretic ankle impedance during walking, differences from healthy data, and elucidates how current clinical metrics correspond to the true values of ankle stiffness and damping during gait.
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Radinmehr H, Ansari NN, Naghdi S, Tabatabaei A, Moghimi E. Comparison of Therapeutic Ultrasound and Radial Shock Wave Therapy in the Treatment of Plantar Flexor Spasticity After Stroke: A Prospective, Single-blind, Randomized Clinical Trial. J Stroke Cerebrovasc Dis 2019; 28:1546-1554. [PMID: 30935809 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 02/16/2019] [Accepted: 03/01/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND This study aimed to compare the effects of therapeutic ultrasound (US) and radial extracorporeal shock wave therapy (rESWT) in the treatment of plantar flexor spasticity after stroke. MATERIALS AND METHODS In this prospective, single-blind, randomized clinical trial, 32 patients (age range 42-78 years; male 19) with stroke were randomly divided into two groups: The US group (n = 16) received the continuous ultrasound, intensity 1.5 w/cm2, frequency 1 MHz, and duration 10 minutes. The rESWT group (n = 16) was treated with rESWT, 0.340 mJ/mm2, 2000 shots. Both groups received the treatments for 1 session. The H-reflex tests of Hmax/Mmax ratio and H-reflex latency, the Modified Modified Ashworth Scale (MMAS), active range of motion (AROM), passive range of motion (PROM), passive plantar flexor torque (PPFT), and the timed "up and go" test (TUG) were blinded assessed at baseline (T0), immediately post-treatment (T1), and one hour follow-up (T2). RESULTS The H-reflex tests did not improve across the groups. However, the MMAS spasticity scores, AROM and PROM, PPFT, and TUG improved significantly within groups. The results found no significant differences between groups for all outcome measures. CONCLUSIONS The US and rESWT had similar effects, and the rESWT was not more effective than the US in improving ankle plantar flexor spasticity after stroke.
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Affiliation(s)
- Hojjat Radinmehr
- Department of Physiotherapy, School of Rehabilitation, Hamadan University of Medical Science, Hamadan, Iran.
| | - Noureddin Nakhostin Ansari
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Science, Tehran, Iran; Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Soofia Naghdi
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Science, Tehran, Iran; Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azade Tabatabaei
- Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Science, Tehran, Iran
| | - Ehsan Moghimi
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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91
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Beyond speed: Gait changes after botulinum toxin injections in chronic stroke survivors (a systematic review). Gait Posture 2019; 70:389-396. [PMID: 30974394 DOI: 10.1016/j.gaitpost.2019.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/03/2019] [Accepted: 03/31/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The mechanisms by which spasticity reductions after botulinum toxin A (BoNT) affect gait in stroke are not well understood. We systematically reviewed the effects of BoNT on spatiotemporal, kinematic, kinetic and electromyographic (EMG) measures during gait. QUESTION What are the effects of botulinum toxin on gait mechanics in stroke patients? METHODS Systematic search using PubMed and Web of Science. We considered all studies that reported laboratory-based and instrumented gait measures as primary or secondary outcomes to determine the effects of BoNT on walking performance in stroke populations only. Selected studies were classified and analysed based on the injection sites. RESULTS A total of 240 articles were identified of which 22 were selected for analysis. Overall, 91% of the studies reported spatiotemporal, 64% kinematics, 23% kinetics, 32% EMG and 23% other gait measures. All but one study found significant effects of BoNT on gait measures using instrumented assessments even when clinical measures (i.e. speed) did not significantly improve. However, the majority of the studies had a high risk of bias. Overall, BoNT improved: a) dorsiflexion during stance, propulsive forces and timing and activity of more proximal musculature with injections in the plantarflexors; b) hip, knee and ankle angles and velocities, coordination and energetic cost with injections in the rectus femoris; c) segmental coordination and energetic cost when several lower limb muscles were injected; and, d) elbow and trunk angles when upper limb muscles were injected. CONCLUSION Instrumented and laboratory measures of gait improve after BoNT injections in different muscle groups even in the absence of clinical changes.
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Efficacy and Safety of Botulinum Toxin Type A for Limb Spasticity after Stroke: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8329306. [PMID: 31080830 PMCID: PMC6475544 DOI: 10.1155/2019/8329306] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 03/13/2019] [Indexed: 01/10/2023]
Abstract
Background Inconsistent data have been reported for the effectiveness of intramuscular botulinum toxin type A (BTXA) in patients with limb spasticity after stroke. This meta-analysis of available randomized controlled trials (RCTs) aimed to determine the efficacy and safety of BTXA in adult patients with upper and lower limb spasticity after stroke. Methods An electronic search was performed to select eligible RCTs in PubMed, Embase, and the Cochrane library through December 2018. Summary standard mean differences (SMDs) and relative risk (RR) values with corresponding 95% confidence intervals (CIs) were employed to assess effectiveness and safety outcomes, respectively. Results Twenty-seven RCTs involving a total of 2,793 patients met the inclusion criteria, including 16 and 9 trials assessing upper and lower limb spasticity cases, respectively. For upper limb spasticity, BTXA therapy significantly improved the levels of muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55; P<0.001), physician global assessment (SMD=0.51; 95% CI 0.35-0.67; P<0.001), and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20; P<0.001), with no significant effects on active upper limb function (SMD=0.49; 95% CI -0.08 to 1.07; P=0.093) and adverse events (RR=1.18; 95% CI 0.72-1.93; P=0.509). For lower limb spasticity, BTXA therapy was associated with higher Fugl-Meyer score (SMD=5.09; 95%CI 2.16-8.01; P=0.001), but had no significant effects on muscle tone (SMD=-0.12; 95% CI -0.83 to 0.59; P=0.736), gait speed (SMD=0.06; 95% CI -0.02 to 0.15; P=0.116), and adverse events (RR=1.01; 95% CI 0.71-1.45; P=0.949). Conclusions BTXA improves muscle tone, physician global assessment, and disability assessment scale in upper limb spasticity and increases the Fugl-Meyer score in lower limb spasticity.
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93
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Clinical study of combined mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients. Int J Rehabil Res 2019; 42:31-35. [PMID: 30211721 PMCID: PMC6382037 DOI: 10.1097/mrr.0000000000000316] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Mirror therapy is a simple, inexpensive, and patient-oriented method that has been shown to reduce phantom sensations and pain caused by amputation and improve range of motion, speed, and accuracy of arm movement and function. Extracorporeal shock wave therapy (ESWT) is a new, reversible, and noninvasive method for the treatment of spasticity after stroke. To investigate the therapeutic effect of the combination of mirror and extracorporeal shock wave therapy on upper limb spasticity in poststroke patients. We randomly assigned 120 patients into four groups: A, B, C, and D. All groups received conventional rehabilitation training for 30 min per day, five times a week, for 4 weeks. Moreover, participants in groups A, B, and C also added mirror therapy, ESWT, and a combination of mirror and ESWT, respectively, for 20 min per day. Motor recovery and spasticity were measured using Fugl–Meyer assessment and modified Ashworth scale. The differences in the Fugl–Meyer assessment and modified Ashworth scale scores in group C were significantly greater than those of group D at all observed time points after treatment and were significantly greater than those of groups A and B (P<0.05), but no significant differences were observed between groups A and B until 12 months. Upper extremity spasticity was improved by combined mirror and ESWT.
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94
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Chen G, Huang C, Liu Y, Zhang Z, Qi X, Shi P, Li D, Lv H, Zhang B. Efficacy and safety of grain moxibustion in hemiplegia: A systematic review and meta-analysis protocol. Medicine (Baltimore) 2019; 98:e15215. [PMID: 31027068 PMCID: PMC6831348 DOI: 10.1097/md.0000000000015215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The increasing morbidity of stroke brings enormous social and economic pressure to the countries. Hemiplegia is the common sequela of stroke patients, which affects their physical activities and daily life, and its optimal treatment is still an urgent problem. In Asian countries, moxibustion therapy is widely combined with rehabilitation in poststroke hemiplegia. Among them, grain moxibustion, due to its concentration on stimulating the acupoints and deep heat penetration, can promote neurorehabilitation after stroke. Therefore, based on the current literatures, the effectiveness and safety of grain moxibustion were systematically evaluated to provide possible alternative therapy for the rehabilitation of hemiplegia. METHODS Studies search for eligible randomized controlled trials (RCTs) that use grain moxibustion as the sole treatment for hemiplegia and their data extraction will be done by two researchers. Mean difference (MD) or relative risk (RR) with fixed or random effect model in terms of 95% confidence interval (CI) will be adopted for the data synthesis. To evaluate the risk of bias, the Cochrane's risk of bias assessment tool will be utilized. The sensitivity or subgroup analysis will also be conducted when meeting high heterogeneity (I > 50%). RESULTS This meta-analysis will provide an authentic synthesis of the grain moxibustion's effect for hemiplegia. CONCLUSION The findings of the review offer updated evidence and identify whether grain moxibustion can be an effective treatment for hemiplegia. PROSPERO REGISTRATION NUMBER PROSPERO CRD 42018117765.
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Affiliation(s)
| | | | - Yunyun Liu
- Guangzhou University of Chinese Medicine
| | | | | | - Peiyu Shi
- Guangzhou University of Chinese Medicine
| | - Dan Li
- Guangzhou University of Chinese Medicine
| | - Huiye Lv
- Guangzhou University of Chinese Medicine
| | - Bin Zhang
- Department of acupuncture and moxibustion, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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95
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Mahmood A, Veluswamy SK, Hombali A, Mullick A, N M, Solomon JM. Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2019; 100:751-768. [DOI: 10.1016/j.apmr.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/15/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
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96
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Shiner CT, Vratsistas-Curto A, Bramah V, Faux SG, Watanabe Y. Prevalence of upper-limb spasticity and its impact on care among nursing home residents with prior stroke. Disabil Rehabil 2019; 42:2170-2177. [PMID: 30929536 DOI: 10.1080/09638288.2018.1555620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Post-stroke spasticity can impair motor function and may cause pain, limb deformity, contracture, and difficulties with limb care. This study aimed to assess the prevalence and burden of post-stroke upper-limb spasticity among nursing home residents.Materials and methods: A multisite, cross-sectional study was conducted across three nursing home facilities. Participants included residents with a confirmed diagnosis of stroke, and nursing staff involved in their care. Residents were assessed using the Tardieu Scale, passive range-of-motion, Abbey Pain scale, Modified Rankin Scale and observation of limb position and skin condition. Nursing staff completed the Arm Activity Measure (ArmA).Results: 264 individuals were screened, 51 had a diagnosis of stroke (19.3%), and 23 consented to participate. 16 participants (70%) demonstrated upper-limb spasticity of at least one joint, median Tardieu score 2 [IQR 2-3]. Pain scores and nurse-rated passive ArmA were significantly higher for patients with spasticity compared to those without (p = 0.003 and p < 0.001, respectively). Greater spasticity correlated with higher pain (rs =0.44) and ArmA scores (rs =0.71).Conclusions: A high proportion (70%) of nursing home residents with stroke demonstrated upper-limb spasticity, associated with pain and passive care difficulties. These data suggest there is an unmet need for spasticity management among nursing-home residents.Implications for rehabilitationUpper-limb spasticity is prevalent among nursing home residents with prior stroke; here, observed in 70% of cases.Spasticity was associated with increased pain and more difficult passive limb care in this population.There is an unmet need for spasticity management among nursing home residents with prior stroke.Efforts should be made to improve access to multidisciplinary spasticity treatment for this vulnerable patient population.
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Affiliation(s)
- Christine T Shiner
- Department of Rehabilitation, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | | | - Valerie Bramah
- Department of Rehabilitation, St Vincent's Hospital Sydney, Sydney, Australia
| | - Steven G Faux
- Department of Rehabilitation, St Vincent's Hospital Sydney, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Yuriko Watanabe
- Department of Rehabilitation, St Vincent's Hospital Sydney, Sydney, Australia
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97
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Wang M, Liu S, Peng Z, Zhu Y, Feng X, Gu Y, Sun J, Tang Q, Chen H, Huang X, Hu J, Chen W, Xiang J, Wan C, Fan G, Lu J, Xia W, Chen L, Wang L, Lu X, Li J. Effect of Tui Na on upper limb spasticity after stroke: a randomized clinical trial. Ann Clin Transl Neurol 2019; 6:778-787. [PMID: 31020002 PMCID: PMC6469238 DOI: 10.1002/acn3.759] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To investigate the efficacy and safety of Tui Na for treating spasticity of the upper limbs of stroke patients. Design A prospective, multicenter, blinded, randomized controlled intervention study. Subjects Stroke patients with upper limb spasticity who were treated between December 2013 and February 2017 in 16 participating institutions in China were randomly assigned to receive either Tui Na plus conventional rehabilitation (Tui Na group, n = 222,) or conventional rehabilitation only (control group, n = 222). Methods Eligible adult patients (aged 18–75 years) were enrolled 1–12 months after stroke and randomly allocated in a 1:1 ratio to the two groups. Outcome assessors were blinded to treatment allocation. Muscle tone in the spastic muscles was evaluated using the Modified Ashworth Scale (MAS), and the primary endpoint was the change in MAS score over 4 weeks of treatment. Results Among patients who had experienced stroke 1–3 months before treatment, the Tui Na group experienced significantly greater reductions in MAS scores for three muscle groups than did the control group after 4 weeks of treatment. These improvements were sustained at the 3‐ and 6‐month follow‐ups. However, among patients who suffered from stroke 4–6 months and 7–12 months before treatment, the change in MAS with treatment did not differ significantly between those who did and those who did not receive Tui Na. No Tui Na‐related adverse events during treatment were reported the groups. Conclusion Tui Na was effective and safe for alleviating poststroke spasticity within 1–3 months after stroke onset.
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Affiliation(s)
- Meng Wang
- The Rehabilitation Medicine Department The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China.,The Second Clinical Medical School Nanjing University of Chinese Medicine Nanjing Jiangsu China
| | - Shouguo Liu
- The Rehabilitation Medicine Department The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Zhihang Peng
- The Teaching and Research Department of Statistics Nanjing Medical University Nanjing Jiangsu China
| | - Yi Zhu
- Rehabilitation Center The Second Affiliated Hospital of HaiNan Medical University Haikou Hainan China
| | - Xiaodong Feng
- The Rehabilitation Department The First Affiliated Hospital of Henan University of Traditional Chinese Medicine Zhengzhou Henan China
| | - Yihuang Gu
- The Second Clinical Medical School Nanjing University of Chinese Medicine Nanjing Jiangsu China
| | - Jianhua Sun
- The Acupuncture Rehabilitation Department Jiangsu Province Hospital of Traditional Chinese Medicine Nanjing Jiangsu China
| | - Qiang Tang
- Rehabilitation Center The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine Haerbin Heilongjiang China
| | - Hongxia Chen
- The Rehabilitation Department Guangdong Provincial Traditional Chinese Medicine Hospital Guangdong China
| | - Xiaolin Huang
- The Rehabilitation Department Tongji Medical College Huazhong University of science & Technology Wuhan Hubei China
| | - Jun Hu
- The Neurological Rehabilitation Department Shanghai University of Traditional Chinese Medicine Shanghai China
| | - Wei Chen
- Rehabilitation Center Xuzhou Central Hospital Xuzhou Jiangsu China
| | - Jie Xiang
- The Rehabilitation Department The Affiliated Hospital of Xuzhou Medical University Xuzhou Jiangsu China
| | - Chunxiao Wan
- The Rehabilitation Department Tianjin Medical University General Hospital Tianjin China
| | - Gangqi Fan
- The Neurology Department Nanjing Hospital of Traditional Chinese Medicine Nanjing Jiangsu China
| | - Jianhu Lu
- The Neurology Department Nanjing Hospital of Traditional Chinese Medicine Nanjing Jiangsu China
| | - Wenguang Xia
- The Rehabilitation Department Hubei Provincial Hospital of Integrated Chinese & Western Medicine Wuhan Hubei China
| | - Liping Chen
- The Rehabilitation Department Lianyungang Chinese Medicine Hospital Lianyungang China
| | - Lihua Wang
- The Rehabilitation Department Dongguan Kanghua Hospital Dongguan China
| | - Xiao Lu
- The Rehabilitation Medicine Department The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Jianan Li
- The Rehabilitation Medicine Department The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
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98
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Makino K, Tilden D, Guarnieri C, Mudge M, Baguley IJ. Cost Effectiveness of Long-Term Incobotulinumtoxin-A Treatment in the Management of Post-stroke Spasticity of the Upper Limb from the Australian Payer Perspective. PHARMACOECONOMICS - OPEN 2019; 3:93-102. [PMID: 29915932 PMCID: PMC6393278 DOI: 10.1007/s41669-018-0086-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND In Australia, the reimbursement of botulinum neurotoxin-A (BoNT-A) on the Pharmaceutical Benefits Scheme for the treatment of moderate to severe spasticity of the upper limb following a stroke (PSS-UL) is restricted to four treatment cycles per upper limb per lifetime. This analysis examined the cost effectiveness of extending the treatment beyond four treatments among patients with an adequate response to previous treatment cycles. METHODS A Markov state transition model was developed to perform a cost-utility analysis of extending the use of incobotulinumtoxin-A beyond the current restriction of four treatment cycles among patients who have shown a successful response in previous treatment cycles ('known responders'). The Markov model followed patients in 12-weekly cycles for 5 years, estimating the proportion of patients with or without response over this period in each of the modelled treatment arms. Post hoc analysis of an open-label extension phase study informed the Markov model. The perspective of the analysis was the Australian healthcare system, meaning only direct healthcare costs were included. Utility values by response status were derived from EQ-5D data from a published double-blind, placebo-controlled study. The primary outcome measure was the incremental cost per quality-adjusted life-year (QALY). Univariate and probabilistic sensitivity analyses were conducted. RESULTS The open-label extension study data demonstrated the probability of treatment response after four injections was greater among 'known responders' than those without prior response. The incremental cost per QALY gained of continued use of incobotulinumtoxin-A beyond the current restriction of four treatments was A$59,911. CONCLUSION Limiting BoNT-A treatment to four cycles per patient per lifetime is likely to be suboptimal in many patients with PSS-UL. Treatment response beyond four cycles is highest among known responders, and allowing such patients to continue treatment beyond four cycles appears cost effective.
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Affiliation(s)
| | | | | | - Mia Mudge
- THEMA Consulting, Sydney, NSW, Australia
| | - Ian J Baguley
- Brain Injury Rehabilitation Service, Westmead Hospital, Sydney, NSW, Australia
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99
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Dorňák T, Justanová M, Konvalinková R, Říha M, Mužík J, Hoskovcová M, Srp M, Navrátilová D, Otruba P, Gál O, Svobodová I, Dušek L, Bareš M, Kaňovský P, Jech R. Prevalence and evolution of spasticity in patients suffering from first‐ever stroke with carotid origin: a prospective, longitudinal study. Eur J Neurol 2019; 26:880-886. [DOI: 10.1111/ene.13902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/07/2019] [Indexed: 11/29/2022]
Affiliation(s)
- T. Dorňák
- Faculty of Medicine Department of Neurology Palacky University and University Hospital OlomoucCzech Republic
| | - M. Justanová
- Faculty of Medicine Department of Neurology Masaryk University and St. Anne's Teaching Hospital BrnoCzech Republic
| | - R. Konvalinková
- First Faculty of Medicine Department of Neurology and Center of Clinical Neuroscience Charles University in Prague PragueCzech Republic
| | - M. Říha
- Department of Rehabilitation Medicine Central Military Hospital PragueCzech Republic
| | - J. Mužík
- Faculty of Medicine Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic
| | - M. Hoskovcová
- First Faculty of Medicine Department of Neurology and Center of Clinical Neuroscience Charles University in Prague PragueCzech Republic
| | - M. Srp
- First Faculty of Medicine Department of Neurology and Center of Clinical Neuroscience Charles University in Prague PragueCzech Republic
| | - D. Navrátilová
- Faculty of Medicine Department of Neurology Palacky University and University Hospital OlomoucCzech Republic
| | - P. Otruba
- Faculty of Medicine Department of Neurology Palacky University and University Hospital OlomoucCzech Republic
| | - O. Gál
- First Faculty of Medicine Department of Neurology and Center of Clinical Neuroscience Charles University in Prague PragueCzech Republic
| | - I. Svobodová
- Faculty of Medicine Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic
| | - L. Dušek
- Faculty of Medicine Institute of Biostatistics and Analyses Masaryk University Brno Czech Republic
| | - M. Bareš
- Faculty of Medicine Department of Neurology Masaryk University and St. Anne's Teaching Hospital BrnoCzech Republic
- Department of Neurology School of Medicine University of Minnesota Minneapolis MN USA
| | - P. Kaňovský
- Faculty of Medicine Department of Neurology Palacky University and University Hospital OlomoucCzech Republic
| | - R. Jech
- First Faculty of Medicine Department of Neurology and Center of Clinical Neuroscience Charles University in Prague PragueCzech Republic
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Jin Y, Jin X, Li J. Fu's subcutaneous needling and constraint-induced movement therapy for a patient with chronic stroke: One-year follow-up case report. Medicine (Baltimore) 2019; 98:e13918. [PMID: 30813122 PMCID: PMC6408031 DOI: 10.1097/md.0000000000013918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Spasticity is a common issue in chronic stroke. To date, no study has reported the long-term (up to 1 year) outcomes of Fu's subcutaneous needling in combination with constraint-induced movement therapy in chronic stroke. This report describes the successful addition of acupuncture on spasticity and arm function in a patient with chronic stroke and arm paresis. PATIENT CONCERNS The patient suffered an infarction in the right posterior limb of the internal capsule 1 year ago, which resulted in hemiparesis in his left (nondominant) hand and arm. The only limitation for constraint-induced movement therapy was insufficient finger extension. The patient was unable to voluntarily extend his interphalangeal or metacarpophalangeal joints beyond the 10 degrees required for constraint-induced movement therapy. However, his muscle tension did not change after the BTX type A injection. DIAGNOSES A 35-year-old male experienced arm paresis after an infarction in the right posterior limb of the internal capsule 1 year before the intervention. INTERVENTIONS The BTX type A injection did not work, so the patient received Fu's subcutaneous needling as an alternative therapy before 5 h of constraint-induced movement therapy for 12 weekdays. OUTCOMES All outcome measures (Modified Ashworth Scale, Fugl-Meyer Assessment, Action Research Arm Test, and Motor Activity Log) substantially improved over the 1-year period. Moreover, during the observation period, the patient's muscle tone and arm function did not worsen. LESSONS As a result of a reduction in spasticity, a reduction of learned nonuse behaviors, or use-dependent plasticity after the combined therapy, the arm functions include volitional movements, and coordination or speed of movements in the paretic arm have been improved. However, we cannot rule out the possibility of an influence of the passage of time or the Hawthorne effect. The costs of the treatment of stroke may be reduced, if this combined therapy proved useful in future controlled studies.
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Affiliation(s)
- Yuanyuan Jin
- Department of Acupuncture and Moxibustion, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, China
| | - Xiaoqing Jin
- Department of Acupuncture and Moxibustion, Zhejiang Hospital, No. 12, Lingyin Road, Xihu District, Hangzhou, China
| | - Jiangru Li
- Department of Rehabilitation Medicine, The Shanghai International Medical Center, No. 4358, Kangxin Road, Pudong New District, Shanghai, China
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