Physical treatment interventions for managing spasticity after stroke

Variation in the rate of recovery in motor function between the upper and lower limbs in patients with stroke: some proposed hypotheses and their implications for research and practice

Background

Stroke results in impairment of motor function of both the upper and lower limbs. However, although it is debatable, motor function of the lower limb is believed to recover faster than that of the upper limb. The aim of this paper is to propose some hypotheses to explain the reasons for that, and discuss their implications for research and practice.

Method

We searched PubMED, Web of Science, Scopus, Embase and CENTRAL using the key words, stroke, cerebrovascular accident, upper extremity, lower extremity, and motor recovery for relevant literature.

Result

The search generated a total of 2,551 hits. However, out of this number, 51 duplicates were removed. Following review of the relevant literature, we proposed four hypotheses: natural instinct for walking hypothesis, bipedal locomotion hypothesis, central pattern generators (CPGs) hypothesis and role of spasticity hypothesis on the subject matter.

Conclusion

We opine that, what may eventually account for the difference, is the frequency of use of the affected limb or intensity of the rehabilitation intervention. This is because, from the above hypotheses, the lower limb seems to be used more frequently. When limbs are used frequently, this will result in use-dependent plasticity and eventual recovery. Thus, rehabilitation techniques that involve high repetitive tasks practice such as robotic rehabilitation, Wii gaming and constraint induced movement therapy should be used during upper limb rehabilitation.

Alternative prognosis of recovery assessment for the hemiparetic limb (APRAHL): a biomarker-free algorithm that predicts recovery potential for stroke patients

Objective

Stroke is a significant cause of disability, rendering patients with inability to perform activities of daily living due to lack of functional recovery. Precise prognosis in the early stage after stroke could enable realistic goal-setting and efficient resource allocation. Prediction algorithms have been tested and validated in the past, but they were using neurological biomarkers; thus, they were time-consuming, difficult to apply, expensive, and potentially harmful. The aim of this study was to create a new prediction algorithm that would not utilize any biomarkers.

Methods

A total of 127 stroke patients prospectively enrolled at day 3 after their stroke (mean age: 71, males n: 84, females n: 43). First, a sum of shoulder abduction and finger extension (SAFE) Medical Research Council (MRC) score was graded at day 3. Secondly, a binarized response was marked by the Mobilization and Simulation of Neuromuscular Tissue (MaSoNT) concept’s basic application on the upper limb. Third, the National Institutes of Health Stroke Scale (NIHSS) score was assessed. All data from the patients were included in a Classification and Regression Tree analysis to predict upper limb function 3 months post-stroke according to the Action Research Arm Test score at week 12.

Results

The Classification And Regression Tree (CART) analysis was performed that combines three different scores in order to predict upper-limb recovery: the SAFE score, MaSoNT’s application response, and the NIHSS. The overall correct prediction of the new algorithm is 69% which is lower than previous algorithms, though not significantly.

Conclusion

This study offers basic data to support the validity of the APRAHL algorithm. The new algorithm is faster and easier, but less accurate. Future studies are needed to create new algorithms that do not involve neurological biomarkers so that they will cost less and be easily applicable by health professionals.

Effect of Stretching of Spastic Elbow Under Intelligent Control in Chronic Stroke Survivors-A Pilot Study

Objective: To assess the short-term effects of strenuous dynamic stretching of the elbow joint using an intelligent stretching device in chronic spastic stroke survivors.

Methods: The intelligent stretching device was utilized to provide a single session of intensive stretching to the spastic elbow joint in the sagittal plane (i.e., elbow flexion and extension). The stretching was provided to the extreme range, safely, with control of the stretching velocity and torque to increase the joint range of motion (ROM) and reduce spasticity and joint stiffness. Eight chronic stroke survivors (age: 52.6 ± 8.2 years, post-stroke duration: 9.5 ± 3.6 years) completed a single 40-min stretching intervention session. Elbow passive and active ROM, strength, passive stiffness (quantifying the non-reflex component of spasticity), and instrumented tendon reflex test of the biceps tendon (quantifying the reflex component of the spasticity) were measured before and after stretching.

Results: After stretching, there was a significant increase in passive ROM of elbow flexion (p = 0.021, r = 0.59) and extension (p = 0.026, r = 0.59). Also, elbow active ROM and the spastic elbow flexors showed a trend of increase in their strength.

Conclusion: The intelligent stretching had a short-term positive influence on the passive movement ROM. Hence, intelligent stretching can potentially be used to repeatedly and regularly stretch spastic elbow joints, which subsequently helps to reduce upper limb impairments post-stroke.

Gait changes following robot-assisted gait training in children with cerebral palsy

This study investigated changes of gait pattern induced by a 4-week robot-assisted gait training (RAGT) in twelve ambulatory spastic diparesis children with cerebral palsy (CP) aged 10.4+/-3.2 years old by using computerized gait analysis (CGA). Pre-post intervention CGA data of children with CP was contrasted to the normative data of typically developing children by using cross-correlation and statistically evaluated by a Wilcoxon test. Significant pre-post intervention changes (p<0.01) include: decreased muscle activity of biceps femoris, rectus femoris, and tibialis anterior; a decrease in range of internal hip joint rotation, higher cadence, step length, and increased stride time. This study suggests that RAGT can be used in muscle reeducation and improved hip joint motion range in ambulatory children with CP.

Pendulum test in chronic hemiplegic stroke population: additional ambulatory information beyond spasticity

Spasticity measured by manual tests, such as modified Ashworth scale (MAS), may not sufficiently reflect mobility function in stroke survivors. This study aims to identify additional ambulatory information provided by the pendulum test. Clinical assessments including Brünnstrom recovery stage, manual muscle test, MAS, Tinetti test (TT), Timed up and go test, 10-m walk test (10-MWT), and Barthel index were applied to 40 ambulant chronic stroke patients. The pendular parameters, first swing excursion (FSE) and relaxation index (RI), were extracted by an electrogoniometer. The correlations among these variables were analyzed by the Spearman and Pearson partial correlation tests. After controlling the factor of motor recovery (Brünnstrom recovery stage), the MAS of paretic knee extensor was negatively correlated with the gait score of TT (r =  − 0.355, p = 0.027), while the FSE revealed positive correlations to the balance score of TT (r = 0.378, p = 0.018). RI were associated with the comfortable speed of 10-MWT (r = 0.367, p = 0.022). These results suggest a decrease of knee extensor spasticity links to a better gait and balance in chronic stroke patients. The pendular parameters can provide additional ambulatory information, as complementary to the MAS. The pendulum test can be a potential tool for patient selection and outcome assessment after spasticity treatments in chronic stroke population.

Development and Preliminary Validation of a Pneumatic Focal Vibration System to the Mitigation of Post-Stroke Spasticity

Some evidence has demonstrated that focal vibration (FV) plays an important role in the mitigation of spasticity. However, the research on developing the FV system to mitigate the spasticity effectively has been seldom reported. To relieve post-stroke spasticity, a new pneumatic FV system has been proposed in this paper. An image processing approach, in which the edge of vibration actuator was identified by the Canny edge detector, was utilized to quantify this system's parameters: the frequency ranging from 44 Hz to 128 Hz and the corresponding amplitude. Taking one FV protocol with the frequency of 87 Hz and the amplitude 0.28 mm of this system as an example, a clinical experiment was carried out. In the clinical experiment, FV was applied over the muscle belly of the antagonist of spastic muscle for twelve chronic spastic stroke patients. Spasticity was quantified by the muscle compliance and area under the curve for muscle (AUC_muscle). The result has demonstrated that, in the state of flexion of spastic muscle, the AUC_muscle and muscle compliance of the spastic muscle significantly increased immediately after FV compared with before-FV, illustrating the mitigation of the spasticity. This study will not only provide a potential tool to relieve post-stroke spasticity, but also contribute to improving the sensory and motor function of patients with other neurological diseases, e.g. spinal cord injury, multiple sclerosis, Parkinson and dystonia, etc.

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

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

Added Value of Dynamic EMG in the Assessment of the Equinus and the Equinovarus Foot Deviation in Stroke Patients and Barriers Limiting Its Usage

Equinus (EFD) and equinovarus foot deviation (EVFD) are the most frequent lower limb deformities in stroke survivors. The equinus component can be triggered by a combination of dorsiflexor deficits, plantar flexor overactivity, muscle stiffness, and contractures. The varus component is typically due to an imbalance between invertor and evertor muscle actions. An improvement in identifying its causes leads to a more targeted treatment. These deformities are typically assessed via a thorough clinical evaluation including the assessment of range of motions, force, spasticity, pain, and observational gait analysis. Diagnostic nerve blocks are also being increasingly used. An advantage of dynamic electromyography (dEMG) is the possibility of measuring muscle activity, overactivity or lack thereof, during specific movements, e.g., activity of both ankle plantar flexors and dorsiflexors during the swing phase of gait. Moreover, fine-wire electrodes can be used to measure the activity of deep muscles, e.g., the tibialis posterior. An impediment to systematic use of dEMG in the assessment of EFD and EVFD, as a complimentary tool to the clinical evaluation, is a lack of evidence of its usefulness. Unfortunately, there are few studies found in literature. In order to fill this void, we studied three pairs of patients suffering from chronic hemiparesis consequent to a stroke, with EFD or EVFD. At the initial evaluation they all displayed the same clinical traits, very similar walking patterns, and an overlapping gait kinematics. However, the patterns of muscle activity differed considerably. dEMG data acquired during walking provided information that was not available from the sole clinical assessment. The contribution of this information to the subsequent clinical and rehabilitation process was discusses along with the barriers that limit the use of dEMG as a routine tool in neurorehabilitation.

The effectiveness of extracorporeal shock wave therapy for improving upper limb spasticity and functionality in stroke patients: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of Extracorporeal Shock Wave Therapy for reducing spasticity and improving functionality of the upper limb in stroke survivors.

DATA SOURCES

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, PEDro, REHABDATA, Scielo, Scopus, Web of Science, Tripdatabase and Epistemonikos from 1980 to April 2020 was carried out.

REVIEW METHODS

The bibliography was screened to identify randomized controlled clinical trials that applied extracorporeal shock waves to upper limb spastic muscles in post-stroke individuals. Two reviewers independently screened references, selected relevant studies, extracted data and assessed risk of bias using the PEDro scale. The primary outcome was spasticity and functionality of the upper limb.

RESULTS

A total of 1,103 studies were identified and 16 randomized controlled trials were finally included (764 individuals) were analyzed. A meta-analysis was performed and a beneficial effect on spasticity was found. The mean difference (MD) on the Modified Ashworth Scale for comparison extracorporeal shock wave versus sham was -0.28; with a 95% confidence interval (CI) from -0.54 to -0.03. The MD of the comparison of extracorporeal shock wave plus conventional physiotherapy versus conventional physiotherapy was -1.78; 95% CI from -2.02 to -1.53. The MD for upper limb motor-function using the Fugl Meyer Assessment was 0.94; 95% CI from 0.42 to 1.47 in the short term and 0.97; 95% CI from 0.19 to 1.74 in the medium term.

CONCLUSION

The extracorporeal shock wave therapy is effective for reducing upper limb spasticity. Adding it to conventional therapy provides an additional benefit.