Pathophysiology of spastic paresis. II: Emergence of muscle overactivity

A survey on the short to medium-term satisfaction of neurological patients treated by functional surgery for the correction of limb deformities

OBJECTIVES

Functional surgery (FS) is often used to correct congenital or acquired deformities in neurological patients. Along with functional results, short- and medium-term patient satisfaction should always be considered a key goal of surgery and rehabilitation. The aim of this study is to assess the short to medium-term satisfaction of patients who underwent FS and its correlation with perceived improvements.

METHODS

Invitation to an anonymous online survey was sent via e-mail to all neurological adult patients or caregivers of children who underwent lower or upper limb FS over the 2018-2020 period. The survey investigated patients' satisfaction with the surgery and the variation in pain, ADLs, level of independence, body image, self-esteem, social interaction skills, participation in social events, leisure activities and sports, and use of orthoses or walking aids. Descriptive data analysis was performed. Correlations were assessed using Kendall's tau.

RESULTS

122 out of 324 adults and 53 out of 163 children's caregivers filled out the questionnaire, with a response rate approaching 40%. Eighty-three percent of adult respondents and 87% of the children's caregivers were satisfied or very satisfied in the short and medium terms and reported their expectations had been met. Satisfaction was significantly correlated (p < 0.01) with improvements in functional abilities, social participation, self-esteem, and pain reduction. Half of the adults and 40% of children stopped using their orthoses or replaced them with lighter ones. Dissatisfaction and worsened conditions were reported by <10% of the respondents.

CONCLUSION

According to patients and caregivers, FS was satisfactory in the short and medium terms, following improvements in all the ICF domains for most patients.

Assessing muscle architecture with ultrasound: implications for spasticity

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

Measurement properties of movement smoothness metrics for upper limb reaching movements in people with moderate to severe subacute stroke

BACKGROUND

Movement smoothness is a potential kinematic biomarker of upper extremity (UE) movement quality and recovery after stroke; however, the measurement properties of available smoothness metrics have been poorly assessed in this group. We aimed to measure the reliability, responsiveness and construct validity of several smoothness metrics.

METHODS

This ancillary study of the REM-AVC trial included 31 participants with hemiparesis in the subacute phase of stroke (median time since stroke: 38 days). Assessments performed at inclusion (Day 0, D0) and at the end of a rehabilitation program (Day 30, D30) included the UE Fugl Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and 3D motion analysis of the UE during three reach-to-point movements at a self-selected speed to a target located in front at shoulder height and at 90% of arm length. Four smoothness metrics were computed: a frequency domain smoothness metric, spectral arc length metric (SPARC); and three temporal domain smoothness metrics (TDSM): log dimensionless jerk (LDLJ); number of submovements (nSUB); and normalized average rectified jerk (NARJ).

RESULTS

At D30, large clinical and kinematic improvements were observed. Only SPARC and LDLJ had an excellent reliability (intra-class correlation > 0.9) and a low measurement error (coefficient of variation < 10%). SPARC was responsive to changes in movement straightness (rSpearman=0.64) and to a lesser extent to changes in movement duration (rSpearman=0.51) while TDSM were very responsive to changes in movement duration (rSpearman>0.8) and not to changes in movement straightness (non-significant correlations). Most construct validity hypotheses tested were verified except for TDSM with low correlations with clinical metrics at D0 (rSpearman<0.5), ensuing low predictive validity with clinical metrics at D30 (non-significant correlations).

CONCLUSIONS

Responsiveness and construct validity of TDSM were hindered by movement duration and/or noise-sensitivity. Based on the present results and concordant literature, we recommend using SPARC rather than TDSM in reaching movements of uncontrolled duration in individuals with spastic paresis after stroke.

TRIAL REGISTRATION

NCT01383512, https://clinicaltrials.gov/ , June 27, 2011.

Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter

In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.

Spasticity Treatment Beyond Botulinum Toxins

Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.

The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

Biochemical, biomechanical and imaging biomarkers of ischemic stroke: Time for integrative thinking

Stroke is one of the leading causes of adult disability affecting millions of people worldwide. Post-stroke cognitive and motor impairments diminish quality of life and functional independence. There is an increased risk of having a second stroke and developing secondary conditions with long-term social and economic impacts. With increasing number of stroke incidents, shortage of medical professionals and limited budgets, health services are struggling to provide a care that can break the vicious cycle of stroke. Effective post-stroke recovery hinges on holistic, integrative and personalized care starting from improved diagnosis and treatment in clinics to continuous rehabilitation and support in the community. To improve stroke care pathways, there have been growing efforts in discovering biomarkers that can provide valuable insights into the neural, physiological and biomechanical consequences of stroke and how patients respond to new interventions. In this review paper, we aim to summarize recent biomarker discovery research focusing on three modalities (brain imaging, blood sampling and gait assessments), look at some established and forthcoming biomarkers, and discuss their usefulness and complementarity within the context of comprehensive stroke care. We also emphasize the importance of biomarker guided personalized interventions to enhance stroke treatment and post-stroke recovery.

Safety of dry needling in stroke patients: a scoping review

INTRODUCTION

Spasticity is a common problem in stroke patients. Treatments of spasticity often have side effects or are insufficiently effective. Dry needling (DN) has been proposed as a potential additional option to consider in the multimodal treatment of post-stroke spasticity, although questions about its safety remain. The goal of this study is to assess the safety of DN in stroke patients.

EVIDENCE ACQUISITION

A systematic search in Medline, Embase, The Cochrane Library, Web of Science, CIHNAL and PEDro was conducted in June 2023. Two reviewers independently screened abstracts according to the eligibility criteria.

EVIDENCE SYNTHESIS

Twenty-five articles were included in this review. Only six studies reported adverse events, all of which were considered minor. None of the included studies reported any serious adverse events. In four of the included studies anticoagulants were regarded as contra-indicative for DN. Anticoagulants were not mentioned in the other included studies.

CONCLUSIONS

There is a paucity of literature concerning the safety of DN in stroke patients. This review is the first to investigate the safety of DN in stroke patients and based on the results there is insufficient evidence regarding the safety of DN in stroke patients.

CLINICAL REHABILITATION IMPACT

Although DN could be a promising treatment in post-stroke spasticity, further research is indicated to investigate its mechanism of action and its effect on outcome. However, before conducting large clinical trials to assess outcome parameters, the safety of DN in stroke patients must be further investigated.

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients

INTRODUCTION

The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment.

RESULTS AND DISCUSSIONS

The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient.

CONCLUSIONS

Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity.

MATERIALS AND METHODS

We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.

Short-term reduction of ankle spasticity after surgical lengthening of the triceps surae in chronic post-stroke patients: a retrospective cohort study

Introduction

In post-stroke patients with equinovarus foot deformity (EVFD), soft tissue rearrangements may contribute to muscle overactivity when a muscle is stretched or tension is applied. Therefore, we investigated the effects of surgically restoring the triceps surae (TS) length and lengthening ability on TS spasticity.

Methods

This retrospective study included chronic post-stroke patients who underwent neuro-orthopedic surgery inclusive of TS lengthening. TS spasticity was measured using the Modified Tardieu Scale (MTS) before and 1 month after surgery, both with the knee extended (KE) and flexed (KF). MTS variations were analyzed using the Wilcoxon test. The time from stroke onset was compared between patients with and without post-surgical spasticity using the t-test. Statistical significance was set at 5%.

Results

A total of 120 patients with EVFD, aged 57 (12) years, ranging from 1 to 36 years from stroke, were included in the study. The median MTS_KE score significantly decreased from 3 (range 0-4) to 2 (0-4) (p < 0.001) after surgery. The MTS score decreased by ≥1 point in more than half of the sample. Notably, 19 and 32 patients were completely relieved from spasticity (MTS = 0) in the KE and KF conditions, respectively. Post-surgical spasticity did not depend on the time since stroke onset (p = 0.560).

Discussion

TS lengthening led to a short-term reduction of spasticity in 41% and 63% of chronic post-stroke patients in the gastro-soleus complex and soleus, respectively, with complete relief observed in 21% and 30% of the sample. Surgical lengthening can be considered an effective treatment that not only restores joint range of motion but also may reduce spasticity, even in chronic patients.

Serious Game with Electromyography Feedback and Physical Therapy in Young Children with Unilateral Spastic Cerebral Palsy and Equinus Gait: A Prospective Open-Label Study

The clinical effects of a serious game with electromyography feedback (EMGs_SG) and physical therapy (PT) was investigated prospectively in children with unilateral spastic cerebral palsy (USCP). An additional aim was to better understand the influence of muscle shortening on function. Thirty children with USCP (age 7.6 ± 2.1 years) received four weeks of EMGs_SG sessions 2×/week including repetitive, active alternating training of dorsi- and plantar flexors in a seated position. In addition, each child received usual PT treatment ≤ 2×/week, involving plantar flexor stretching and command strengthening on dorsi- and plantar flexors. Five-Step Assessment parameters, including preferred gait velocity (normalized by height); plantar flexor extensibility (XV1); angle of catch (XV3); maximal active ankle dorsiflexion (XA); and derived coefficients of shortening, spasticity, and weakness for both soleus and gastrosoleus complex (GSC) were compared pre and post treatment (t-tests). Correlations were explored between the various coefficients and gait velocities at baseline. After four weeks of EMGs_SG + PT, there was an increase in normalized gait velocity from 0.72 ± 0.13 to 0.77 ± 0.13 m/s (p = 0.025, d = 0.43), a decrease in coefficients of shortening (soleus, 0.10 ± 0.07 pre vs. 0.07 ± 0.08 post, p = 0.004, d = 0.57; GSC 0.16 ± 0.08 vs. 0.13 ± 0.08, p = 0.003, d = 0.58), spasticity (soleus 0.14 ± 0.06 vs. 0.12 ± 0.07, p = 0.02, d = 0.46), and weakness (soleus 0.14 ± 0.07 vs. 0.11 ± 0.07, p = 0.005, d = 0.55). At baseline, normalized gait velocity correlated with the coefficient of GSC shortening (R = -0.43, p = 0.02). Four weeks of EMGs_SG and PT were associated with improved gait velocity and decreased plantar flexor shortening. A randomized controlled trial comparing EMGs_SG and conventional PT is needed.

Case report: Intrathecal baclofen therapy improved gait pattern in a stroke patient with spastic dystonia

Background

Intrathecal baclofen (ITB) therapy, a viable alternative for unsuitable candidates of conventional spasticity medications, is a preferred method of administration over the oral route. Owing to its enhanced bioavailability, ITB ensures a more effective delivery at the target site.

Objective

There is a lack of conclusive evidence regarding the use of ITB treatment in managing ambulatory patients with spastic dystonia. Before ITB pump implantation, patients commonly undergo an ITB bolus injection trial to rule out potential adverse reactions and verify the therapeutic effects on hypertonic issues. In this report, we highlight a case of spastic dystonia, particularly focusing on an ambulatory patient who demonstrated significant improvement in both the modified Ashworth scale (MAS) score and gait pattern following the ITB injection trial.

Case report

This case report outlines the medical history of a 67-year-old male diagnosed with left-side hemiplegia and spastic dystonia, resulting from his second episode of intracranial hemorrhage in the right thalamus. An ITB injection trial was initiated because the patient was not suitable for continued botulinum toxin injections and oral medications. This was due to the persistent occurrence of spastic dystonia in both the upper and lower extremities. The patient underwent a four-day ITB injection trial with progressively increasing doses, resulting in improved MAS scores and gait parameters, including cadence, step length, step time, stride length, and stride time were increased. Particularly, kinematic gait analysis demonstrates a substantial improvement of increased knee flexion in the swing phase in stiff knee gait pattern. These findings indicated a gradual reduction in spasticity-related symptoms, signifying the positive effect of the ITB injection trial. The patient eventually received an ITB pump implantation.

Conclusion

In this post-stroke patient with spastic dystonia, ITB therapy has demonstrated effective and substantial management of spasticity, along with improvement in gait patterns.

Mechanical properties change of immobilized skeletal muscle in short position measured by shear wave elastography and pure shearing test

The purpose of this study was to evaluate the effects of immobilization on mechanical properties of skeletal muscle over the time. An in vivo rat model was used to investigate the shear modulus change of the flexor carpi ulnaris (FCU) in a short position. Measurements were performed by shear wave elastography (SWE) to compare contralateral and immobilized cases. The results showed a significant increase of 18.1% (p = 3.86. 10-7) in the shear modulus of immobilized skeletal muscle after two weeks (D14) when compared with the contralateral case. For the purposes of comparison, in vitro mechanical pure shearing tests were performed on samples collected from the skeletal muscles of the same rats. Although the difference between contralateral and immobilized cases was 17.6% (p = 0.32) at D14, the shear modulus difference was 35.7% (p = 0.0126 and p = 1.57.10-5 for immobilization and contralateral respectively) between in vivo and in vitro approaches. The mechanical properties changes were then correlated with the density of collagen from histological analysis, and it was shown that the contralateral collagen surface density was 25.4% higher than the immobilized density at D14 (p = 0.001). Thus, the results showed the feasibility of the comparison between the two approaches, which can surely be improved by optimizing the experimental protocols.

Corticospinal tract: a new hope for the treatment of post-stroke spasticity

Stroke is the third leading cause of death and disability worldwide. Post-stroke spasticity (PSS) is the most common complication of stroke but represents only one of the many manifestations of upper motor neuron syndrome. As an upper motor neuron, the corticospinal tract (CST) is the only direct descending motor pathway that innervates the spinal motor neurons and is closely related to the recovery of limb function in patients with PSS. Therefore, promoting axonal remodeling in the CST may help identify new therapeutic strategies for PSS. In this review, we outline the pathological mechanisms of PSS, specifically their relationship with CST, and therapeutic strategies for axonal regeneration of the CST after stroke. We found it to be closely associated with astroglial scarring produced by astrocyte activation and its secretion of neurotrophic factors, mainly after the onset of cerebral ischemia. We hope that this review offers insight into the relationship between CST and PSS and provides a basis for further studies.

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

BACKGROUND

Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients' functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC).

OBJECTIVE

To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment.

METHODS

A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC.

RESULTS

Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated.

CONCLUSION

The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phases to prevent complications such as pain and improve patients' recovery. Additionally, this approach could enhance patients' ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.

Cortical effects of wrist tendon vibration during an arm tracking task in chronic stroke survivors: An EEG study

The purpose of this study was to characterize changes in cortical activity and connectivity in stroke survivors when vibration is applied to the wrist flexor tendons during a visuomotor tracking task. Data were collected from 10 chronic stroke participants and 10 neurologically-intact controls while tracking a target through a figure-8 pattern in the horizontal plane. Electroencephalography (EEG) was used to measure cortical activity (beta band desynchronization) and connectivity (beta band task-based coherence) with movement kinematics and performance error also being recorded during the task. All participants came into our lab on two separate days and performed three blocks (16 trials each, 48 total trials) of tracking, with the middle block including vibration or sham applied at the wrist flexor tendons. The order of the sessions (Vibe vs. Sham) was counterbalanced across participants to prevent ordering effects. During the Sham session, cortical activity increased as the tracking task progressed (over blocks). This effect was reduced when vibration was applied to controls. In contrast, vibration increased cortical activity during the vibration period in participants with stroke. Cortical connectivity increased during vibration, with larger effect sizes in participants with stroke. Changes in tracking performance, standard deviation of hand speed, were observed in both control and stroke groups. Overall, EEG measures of brain activity and connectivity provided insight into effects of vibration on brain control of a visuomotor task. The increases in cortical activity and connectivity with vibration improved patterns of activity in people with stroke. These findings suggest that reactivation of normal cortical networks via tendon vibration may be useful during physical rehabilitation of stroke patients.

ToulGaitViz: a tool for the systematic description of lower limb clearance during the swing phase of hemiparetic gait after stroke. A cohort study

BACKGROUND

In post-stroke hemiparetic subjects, a systematic and quantified description of the shortening default and compensatory movements during the swing phase of gait is essential to guide treatments and assess the impact of therapeutic interventions. However, such a systematic approach does not exist in the current clinical practice.

AIM

The aim of this study was to present a method improving the quantification and visualization of the kinematics of both lower limbs during the swing phase of gait, more specifically the origin of shortening default and the weight of compensations, based on a tool specifically developed: ToulGaitViz.

DESIGN

Observational cohort study.

SETTING

Three-dimensional kinematic gait analyses of outpatients evaluated in Toulouse university hospital.

POPULATION

ToulGaitViz was applied to 151 post-stroke hemiparetic participants and 48 healthy control participants.

METHODS

ToulGaitViz is a standalone software allowing to compute 1) limb clearance as the sum of the shortening related to hip, knee and ankle flexion in the sagittal plane; 2) compensations related to the abduction of the limb and hip hiking at mid-swing. Both centimetric and angular values of the clearance were reported as well as their correlations with walking speed.

RESULTS

Overall, the contribution of compensations in clearance was higher in post-stroke hemiparetic subjects than in healthy control participants with both centimetric (130% vs. 33%; P<0.001) and angular methods (23% vs. 1.4%; P<0.001). The centimetric method better represents the specific contribution of each segment to the clearance than the angular method. Symbolically, mean kinematic data from the cohort supports the claim that 2° of pelvic obliquity is equivalent to 10° of knee flexion to increase clearance by 1 cm, emphasizing the non-proportionality between the angular values and the actual contribution to the shortening. ToulGaitViz allows visualization of clearance, segmental shortening and compensation evolution before and after any therapeutic intervention with quantitative and comprehensive data.

CONCLUSIONS

The ToulGaitViz could be systematically used in clinical practice to extract relevant kinematic data from the origin of shortening default and the weight of compensations.

CLINICAL REHABILITATION IMPACT

This tool allows better understanding of the mechanisms of action of treatments to better link them to the subjects' needs.

Broader Estimates of Gastrocnemius Activity Generated a More Representative Cocontraction Index: A Study in Pediatric Population

The electromyography (EMG) cocontraction index (CCI) given by the antagonistic/agonistic Root Mean Square (RMS) amplitude ratio of the same muscle is a qualified biomarker used for spastic cocontraction quantification and management in cerebral palsy children. However, this normative EMG ratio is likely subject to a potential source of errors with biased estimates when measuring the gastrocnemius plantar flexors activity. Due to the uneven distribution of electrical activity within the muscle volume, cocontraction levels can be misestimated, if EMGs are obtained from the sole traditional bipolar sensor location recommended by SENIAM. This preliminary study, on 10 healthy children (mean age 10 yr), investigated whether surface EMG detected proximally and distally via two pairs of bipolar electrodes, within the medial gastrocnemius (MG), provides a significant difference in CCI estimates during non-dynamic (isometric dorsiflexion) and dynamic (swing phases of gait) conditions. Gait cycles were extracted from Inertial Measurement Unit sensors. Medial gastrocnemius activity was greater distally than proximally during plantar flexion when it acts as an agonist (~24±18%) and it was greater proximally during dorsiflexion (~23±9%) when it is acting as an antagonist. As a direct consequence, CCI estimates from the conventional sensor location were significantly different (~36%) from the CCIs computed by considering broader MG regions. This difference arose in all subjects during isometric efforts and in two of 10 healthy children during the swing phase of gait who presented cocontraction patterns ( [Formula: see text]). EMG bipolar sampling encompassing proximal and distal gastrocnemius muscle regions may reduce bias in CCI computation and provide a more representative and accurate cocontraction index that is especially important for comparisons to the diseased state.

Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy

BACKGROUND

Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood.

METHODS

We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales.

RESULTS

The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms.

CONCLUSIONS

We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.

Reliability of the Modified Frenchay Scale for the Assessment of Upper Limb Function in Adults With Hemiparesis

OBJECTIVES

To investigate the reliability of the Modified Frenchay Scale (MFS) in adults with hemiparesis.

DESIGN

Prospective analysis of videos.

SETTING

Study conducted in a Neurorehabilitation Unit of a University Hospital.

PARTICIPANTS

Fifty-one patients (17 women [33%], age 46±15, time since injury 5.2±6.7 years) with hemiparesis secondary to stroke (N=47), tumor (N=3), or spinal cord injury (N=1) were enrolled.

INTERVENTION

The MFS measures active upper limb function in spastic hemiparesis based on a video recording of 10 daily living tasks, each rated from 0 to 10. Six tasks are bimanual and 4 are unimanual with the paretic hand. MFS videos performed in routine care of patients with hemiparesis between 2015 and 2021 were collected. After a 3-hour group training session, each MFS video was assessed twice, 1 week apart by 4 rehabilitation professionals with various levels of experience in using the scale.

MAIN OUTCOME MEASURES

Internal consistency was determined using Cronbach's alpha. Intra- and inter-rater reliability was measured using intraclass correlation coefficients (ICC, mean [95% CI]), mean differences between ratings and minimal detectable change (MDC). Bland-Altman plots were also performed for inter-rater assessments.

RESULTS

The mean overall MFS score was 4.95±1.20 with no floor or ceiling effect. Cronbach's α was 0.97. For the overall MFS score, intra- and inter-rater ICCs were 0.99[0.99;1.00] and 0.97[0.95;0.98], respectively; mean intra- and inter-rater differences were 0.10±0.04 and 0.24±0.12, respectively; and MDC were 0.17 and 0.37, respectively.

CONCLUSIONS

The MFS is an internally consistent and reliable scale to assess upper limb function in adults with hemiparesis.

Spastic dystonia: Still a valid term

Hypertonia in childhood may arise because of a variable combination of neuronal and non-neuronal factors. Involuntary muscle contraction may be due to spasticity or dystonia, which represent disorders of the spinal reflex arch and of central motor output respectively. Whilst consensus definitions for dystonia have been established, definitions of spasticity vary, highlighting the lack of a single unifying nomenclature in the field of clinical movement science. The term spastic dystonia refers to involuntary tonic muscle contraction in the context of an upper motor neuron (UMN) lesion. This review considers the utility of the term spastic dystonia, exploring our understanding of the pathophysiology of dystonia and the UMN syndrome. An argument is advanced that spastic dystonia is a valid construct that warrants further exploration. WHAT THIS PAPER ADDS: There is no single universally accepted definitions for terms commonly used to describe motor disorders. Spasticity and dystonia are phenomenologically and pathophysiologically distinct entities. Spastic dystonia represents a subset of dystonia, but with pathophysiological mechanisms more in common with spasticity.

Emerging theory of sensitization in post-stroke muscle spasticity

Spasticity, characterized by a velocity-dependent increase in muscle tone and exaggerated reflexes, is a common complication in individuals with upper motor neuron syndrome, such as stroke survivors. Sensitization, the heightened responsiveness of the nervous system to sensory stimuli, has emerged as a potential cause of spasticity. This perspective article explores three emerging treatments targeting sensitization. Recent studies have investigated novel treatment modalities for spasticity, including Extracorporeal Shockwave Therapy (ESWT), repetitive peripheral magnetic stimulation (rPMS), and needling. ESWT has shown promising results in reducing spasticity in both the upper and lower extremities, potentially through mechanisms such as nitric oxide production, rheological property changes, and neuromuscular transmission dysfunction. rPMS offers a non-invasive approach that may reduce spasticity by increasing sensory input, enhancing cortical activation, and exerting tissue-softening effects. Needling has also demonstrated positive effects on spasticity reduction. The high heterogeneity observed indicates the need for more rigorous research to confirm these findings. Recently, mechanical needling and sterile water injection invented by the author is also promising for reducing spasticity through removing sensitization. In conclusion, the emerging treatment options discussed in this perspective article provide promising avenues for addressing sensitization in spasticity and improving motor function. However, further research is needed to validate their findings, optimize treatment protocols, and investigate their long-term effects on motor recovery and overall quality of life in individuals with spasticity.

Ankle-Foot-Orthosis "Hermes" Compensates Pathological Ankle Stiffness of Chronic Stroke-A Proof of Concept

Individuals with an upper motor neuron syndrome, e.g., stroke survivors, may have a pathological increase of passive ankle stiffness due to spasticity, that impairs ankle function and activities such as walking. To improve mobility, walking aids such as ankle-foot orthoses and orthopaedic shoes are prescribed. However, these walking aids generally limit the range of motion (ROM) of the foot and may therewith negatively influence activities that require a larger ROM. Here we present a new ankle-foot orthosis "Hermes", and its first experimental results from four hemiparetic chronic stroke patients. Hermes was designed to facilitate active ankle dorsiflexion by mechanically compensating the passive ankle stiffness using a negative-stiffness mechanism. Four levels of the Hermes' stiffness compensation (0%, 35%, 70% and 100%) were applied to evaluate active ROM in a robotic ankle manipulator and to test walking feasibility on an instrumented treadmill, in a single session. The robotic tests showed that Hermes successfully compensated the ankle joint stiffness in all four patients and improved the active dorsiflexion ROM in three patients. Three patients were able to walk with Hermes at one or more Hermes' stiffness compensation levels and without reducing their preferred walking speeds compared to those with their own walking aids. Despite a small sample size, the results show that Hermes holds great promise to support voluntary ankle function and to benefit walking and daily activities.

Immediate Effects of Anti-Spastic Epidural Cervical Spinal Cord Stimulation on Functional Connectivity of the Central Motor System in Patients with Stroke- and Traumatic Brain Injury-Induced Spasticity: A Pilot Resting-State Functional Magnetic Resonance Imaging Study

OBJECTIVE

Spinal cord stimulation (SCS) is one approach to the potential improvement of patients with post-stroke or post-traumatic spasticity. However, little is known about whether and how such interventions alter supraspinal neural systems involved in the pathogenesis of spasticity. This pilot study investigated whether epidural spinal cord stimulation at the level of the C3-C5 cervical segments, aimed at reducing spasticity, alters the patterns of functional connectivity of the brain.

METHODS

Eight patients with spasticity in the right limbs as a result of left cerebral hemisphere damage (due to hemorrhagic and ischemic stroke or traumatic and anoxic brain injury) were assessed with fMRI immediately before and immediately after short-term (1 to 6 days) test cervical epidural SCS therapy. Eight demographically and clinically comparable patients with spasticity in the right extremities due to a left hemisphere ischemic stroke and brain injury who received conventional therapy were examined as a control group. All patients also had paresis of one or two limbs and hyperreflexia.

RESULTS

After the SCS therapy, there were three main findings: (1) higher functional connectivity of the brainstem to the right premotor cortex and changes in functional connectivity between cortical motor areas, (2) increased functional connectivity between the right and left lateral nodes of the sensorimotor network, and (3) a positive correlation between decreased spasticity in the right leg and increased functional connectivity within the right hemisphere sensorimotor cortex. All these changes in functional connectivity occurred with a statistically significant decrease in spasticity, as assessed using the modified Ashworth scale. The control group showed no decrease in spasticity or increase in functional connectivity in any of the seeds of interest. On the contrary, a decrease in functional connectivity of the brainstem and right postcentral gyrus was observed in this group during the observation period.

CONCLUSIONS

We were thus able to detect intrinsic brain connectivity rearrangements that occurred during spasticity mitigation following short epidural SCS therapy.

SIGNIFICANCE

The clinical results obtained confirmed the efficacy of short-term anti-spastic SCS therapy. The obtained data on functional rearrangements of the central motor system may shed light on the mechanism of antispastic action of this procedure.

Comparing the Effect of Implanted Peroneal Nerve Stimulation and Ankle-Foot Orthosis on Gait Kinematics in Chronic Hemiparesis: A Randomized Controlled Trial

OBJECTIVE

Impaired ankle dorsiflexion in hemiparesis may be treated with ankle-foot orthosis or functional electrical stimulation. Semi-implanted selective functional electrical stimulation uses independent stimulations of deep and superficial peroneal nerves. The aim of this study was to compare gait kinematics using ankle-foot orthosis or semi-implanted selective functional electrical stimulation over 6 months in hemiparesis.

METHODS

Subjects with chronic hemiparesis, randomized into ankle-foot orthosis or semi-implanted selective functional electrical stimulation groups, underwent comfortable gait analysis without and with device OFF and ON, before, and 3 and 6 months after treatment onset. The effects of condition, visit and group on gait kinematics (analysis of variance; ANOVA) were analysed.

RESULTS

A total of 27 subjects were included (ankle-foot orthosis, n = 13; semi-implanted selective functional electrical stimulation, n = 14). The only between-group difference in changes from OFF to ON conditions was a deteriorated ankle dorsiflexion speed with ankle-foot orthosis at month 6 (condition*group, p = 0.04; ankle-foot orthosis, -60%, p = 0.02; semi-implanted selective functional electrical stimulation, non significant). Both groups pooled, from OFF to ON gait speed (+ 0.07 m/s; + 10%), cadence (+ 4%), step length (+ 6%) and peak ankle dorsiflexion (+ 6°) increased, and peak ankle inversion (-5°) and peak knee flexion (-2°) decreased (p < 0.001); finally, peak knee flexion in the OFF condition increased (+ 2°, p = 0.03).

CONCLUSION

Semi-implanted selective functional electrical stimulation and ankle-foot orthosis similarly impacted gait kinematics in chronic hemiparesis after 6 months of use. Ankle dorsiflexion speed in swing deteriorated markedly with ankle-foot orthosis.

CHECGAIT: A Functional Electrical Stimulation Clinical Pathway to Reduce Foot Drop during Walking in Adult Patients with Upper Motor Neuron Lesions

Foot drop during the swing phase of gait and at initial foot contact is a current kinematic abnormality that can occur following an upper motor neuron (UMN) lesion. Functional electrical stimulation (FES) of the common peroneal nerve through an assistive device is often used in neuro-rehabilitation to help patients regain mobility. Although there are FES-specific guideline recommendations, it remains a challenge for clinicians to appropriately select patients eligible for the daily use of FES devices, as very few health insurance systems cover its cost in Europe. In Luxembourg, since 2018, successfully completing an FES clinical pathway called CHECGAIT is a prerequisite to receiving financial coverage for FES devices from the national health fund (Caisse Nationale de Santé-CNS). This study describes the structure and steps of CHECGAIT and reports our experience with a cohort of 100 patients enrolled over a three-year period. The clinical and gait outcomes of all patients were retrospectively quantified, and a specific analysis was performed to highlight differences between patients with and without an FES device prescription at the end of a CHECGAIT. Several significant gait differences were found between these groups. These results and CHECGAIT may help clinicians to better select patients who can most benefit from this technology in their daily lives. In addition, CHECGAIT could provide significant savings to public health systems by avoiding unnecessary deliveries of FES devices.

Chronic striatal cholinergic interneuron excitation induces clinically-relevant dystonic behavior in mice

Dystonia is common, debilitating, often medically refractory, and difficult to diagnose. The gold standard for both clinical and mouse model dystonia evaluation is subjective assessment, ideally by expert consensus. However, this subjectivity makes translational quantification of clinically-relevant dystonia metrics across species nearly impossible. Many mouse models of genetic dystonias display abnormal striatal cholinergic interneuron excitation, but few display subjectively dystonic features. Therefore, whether striatal cholinergic interneuron pathology causes dystonia remains unknown. To address these critical limitations, we first demonstrate that objectively quantifiable leg adduction variability correlates with leg dystonia severity in people. We then show that chemogenetic excitation of striatal cholinergic interneurons in mice causes comparable leg adduction variability in mice. This clinically-relevant dystonic behavior in mice does not occur with acute excitation, but rather develops after 14 days of ongoing striatal cholinergic interneuron excitation. This requirement for prolonged excitation recapitulates the clinically observed phenomena of a delay between an inciting brain injury and subsequent dystonia manifestation and demonstrates a causative link between chronic striatal cholinergic interneuron excitation and clinically-relevant dystonic behavior in mice. Therefore, these results support targeting striatal ChIs for dystonia drug development and suggests early treatment in the window following injury but prior to dystonia onset.

One Sentence Summary

Chronic excitation of dorsal striatal cholinergic interneuron causes clinically-relevant dystonic phenotypes in mice.

Leg Cycling Leads to Improvement of Spasticity by Enhancement of Presynaptic Inhibition in Patients with Cerebral Palsy

OBJECTIVE

The purpose of this study was to investigate if leg cycling could reduce lower extremity spasticity in patients with cerebral palsy (CP). In addition, we investigated whether the intervention could cause changes in the modulation of presynaptic inhibition.

METHODS

This study was a quasi-experimental study, with pretest-posttest for 1 group. Participants in this experiment were eight adult patients with CP with lower extremity spasticity. Spasticity parameters assessed were the amplitude of soleus maximum Hoffmann's reflex (Hmax) and maximum angular velocity (MAV) of knee flexion measured using the pendulum test. D1 inhibition, which seems to be related to the presynaptic inhibition, was recorded by measuring soleus Hoffmann's reflex (H-reflex) with conditioned electric stimuli to the common peroneal nerve.

RESULTS

D1 inhibition was significantly enhanced immediately by the cycling intervention. The amplitude of the soleus Hmax was significantly depressed, and there was significant difference in Hmax/maximum M-wave. The MAV was increased due to inhibition of the stretch reflex.

CONCLUSION

Leg cycling suppressed stretch reflex and H-reflex, and caused plasticity of inhibitory circuits in patients with CP with lower extremity spasticity. These findings strongly suggest that lower extremity spasticity can be improved by cycling movements.

Measuring resistance to externally induced movement of the wrist joint in chronic stroke patients using an objective hand-held dynamometer

Objective

We evaluated the resistance to externally induced wrist extension in chronic stroke patients. We aimed to objectively measure and distinguish passive (muscle and soft tissue stiffness) and active (spasticity and spastic dystonia) components of the resistance.

Methods

We used a hand-held dynamometer, which measures torque, joint movement and electromyography (EMG) simultaneously, to assess the resistance to externally induced wrist extension. Slow and fast stretches were applied to the affected and unaffected wrists in 57 chronic stroke patients (57 ± 11 years). We extracted from the data parameters that represent passive and muscle activity components and assessed the validity, test-retest reliability and the clinical utility of the measurement.

Results

The analysis showed (1) a significant difference in the passive and muscle activity components between the affected and unaffected sides; (2) a significant correlation between passive and muscle activity components and the modified Ashworth scale (MAS); (3) a significant difference between the subgroups of patients stratified by the MAS; (4) an excellent intra-rater reliability on each of the passive and muscle activity components with intra-class coefficients between 0.92 and 0.99; (5) and small measurement error.

Conclusions

Using a hand-held dynamometer, we were able to objectively measure the resistance to muscle stretch in the wrist joint in chronic stroke patients and discriminate muscle overactivity components from muscle and soft tissue stiffness. We demonstrated validity, test-retest reliability and the clinical utility of the measurement.

Significance

Quantification of the different components of resistance to externally induced movement enables the objective evaluation of neurorehabilitation effects in chronic stroke patients.

Increasing the Passive Range of Joint Motion in Stroke Patients Using Botulinum Toxin: The Role of Pain Relief

By blocking the release of neurotransmitters, botulinum toxin A (BoNT-A) is an effective treatment for muscle over-activity and pain in stroke patients. BoNT-A has also been reported to increase passive range of motion (p-ROM), the decrease of which is mainly due to muscle shortening (i.e., muscle contracture). Although the mechanism of action of BoNT-A on p-ROM is far from understood, pain relief may be hypothesized to play a role. To test this hypothesis, a retrospective investigation of p-ROM and pain was conducted in post-stroke patients treated with BoNT-A for upper limb hypertonia. Among 70 stroke patients enrolled in the study, muscle tone (Modified Ashworth Scale), pathological postures, p-ROM, and pain during p-ROM assessment (Numeric Rating Scale, NRS) were investigated in elbow flexors (48 patients) and in finger flexors (64 patients), just before and 3-6 weeks after BoNT-A treatment. Before BoNT-A treatment, pathological postures of elbow flexion were found in all patients but one. A decreased elbow p-ROM was found in 18 patients (38%). Patients with decreased p-ROM had higher pain-NRS scores (5.08 ± 1.96, with a pain score ≥8 in 11% of cases) than patients with normal p-ROM (0.57 ± 1.36) (p < 0.001). Similarly, pathological postures of finger flexion were found in all patients but two. A decreased finger p-ROM was found in 14 patients (22%). Pain was more intense in the 14 patients with decreased p-ROM (8.43 ± 1.74, with a pain score ≥ 8 in 86% of cases) than in the 50 patients with normal p-ROM (0.98 ± 1.89) (p < 0.001). After BoNT-A treatment, muscle tone, pathological postures, and pain decreased in both elbow and finger flexors. In contrast, p-ROM increased only in finger flexors. The study discusses that pain plays a pivotal role in the increase in p-ROM observed after BoNT-A treatment.

Spasticity evaluation and management tools

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient-reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient-reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met.

A Bayesian Network Meta-Analysis and Systematic Review of Guidance Techniques in Botulinum Toxin Injections and Their Hierarchy in the Treatment of Limb Spasticity

Accurate targeting of overactive muscles is fundamental for successful botulinum neurotoxin (BoNT) injections in the treatment of spasticity. The necessity of instrumented guidance and the superiority of one or more guidance techniques are ambiguous. Here, we sought to investigate if guided BoNT injections lead to a better clinical outcome in adults with limb spasticity compared to non-guided injections. We also aimed to elucidate the hierarchy of common guidance techniques including electromyography, electrostimulation, manual needle placement and ultrasound. To this end, we conducted a Bayesian network meta-analysis and systematic review with 245 patients using the MetaInsight software, R and the Cochrane Review Manager. Our study provided, for the first time, quantitative evidence supporting the superiority of guided BoNT injections over the non-guided ones. The hierarchy comprised ultrasound on the first level, electrostimulation on the second, electromyography on the third and manual needle placement on the last level. The difference between ultrasound and electrostimulation was minor and, thus, appropriate contextualization is essential for decision making. Taken together, guided BoNT injections based on ultrasound and electrostimulation performed by experienced practitioners lead to a better clinical outcome within the first month post-injection in adults with limb spasticity. In the present study, ultrasound performed slightly better, but large-scale trials should shed more light on which modality is superior.

Anti-spastic effect of contralesional dorsal premotor cortex stimulation in stroke patients with moderate-to-severe spastic paresis: a randomized, controlled pilot trial

OBJECTIVE

This study aimed at investigating the effect of a single-session repetitive transcranial magnetic stimulation (rTMS) of the contralesional dorsal premotor cortex on poststroke upper-limb spasticity.

MATERIAL AND METHODS

The study consisted of the following three independent parallel arms: inhibitory rTMS (n = 12), excitatory rTMS (n = 12), and sham stimulation (n = 13). The primary and secondary outcome measures were the Modified Ashworth Scale (MAS) and F/M amplitude ratio, respectively. A clinically meaningful difference was defined as a reduction in at least one MAS score.

RESULTS

There was a statistically significant change in MAS score within only the excitatory rTMS group over time [median (interquartile range) of - 1.0 (- 1.0 to - 0.5), p = 0.004]. However, groups were comparable in terms of median changes in MAS scores (p > 0.05). The proportions of patients achieving at least one MAS score reduction (9/12 in the excitatory rTMS group, 5/12 in the inhibitory rTMS group, and 5/13 in the control group) were also comparable (p = 0.135). For the F/M amplitude ratio, main time effect, main intervention effect, and time-intervention interaction effect were not statistically significant (p > 0.05).

CONCLUSIONS

Modulation of the contralesional dorsal premotor cortex with a single-session of excitatory or inhibitory rTMS does not appear to have an immediate anti-spastic effect beyond sham/placebo. The implication of this small study remains unclear and further studies into excitatory rTMS for the treatment of moderate-to-severe spastic paresis in poststroke patients should be undertaken.

CLINICAL TRIAL REGISTRATION NO

NCT04063995 (clinicaltrials.gov).

Research progress in extracorporeal shock wave therapy for upper limb spasticity after stroke

Spasticity is one of the most common complications after stroke. With the gradual intensification of spasticity, stroke patients will have a series of problems such as joint ankylosis and movement restriction, which affect the daily activities and increase the burden on patients' families, medical staff and society. There are many ways to treat post-stroke spasticity before, including physical therapy and exercise therapy, drug therapy, surgery and so on, but not satisfied because of a few shortcomings. In recent years, many researchers have applied extracorporeal shock wave therapy (ESWT) for the treatment of post-stroke spasm and achieved good clinical effect, because it is non-invasive, safe, easy to operate, low cost and other advantages compared with other treatment methods. This article reviews the research progress and existing problems of ESWT in the treatment of post-stroke spasticity.

Automatic Identification of Involuntary Muscle Activity in Subacute Patients with Upper Motor Neuron Lesion at Rest-A Validation Study

Sustained involuntary muscle activity (IMA) is a highly disabling phenomenon that arises in the acute phase of an upper motor neuron lesion (UMNL). Wearable probes for long-lasting surface EMG (sEMG) recordings have been recently recommended to detect IMA insurgence and to quantify its evolution over time, in conjunction with a complex algorithm for IMA automatic identification and classification. In this study, we computed sensitivity (Se), specificity (Sp), and overall accuracy (Acc) of this algorithm by comparing it with the classification provided by two expert assessors. Based on sample size estimation, 6020 10 s-long sEMG epochs were classified by both the algorithm and the assessors. Epochs were randomly extracted from long-lasting sEMG signals collected in-field from 14 biceps brachii (BB) muscles of 10 patients (5F, age range 50-71 years) hospitalized in an acute rehabilitation ward following a stroke or a post-anoxic coma and complete upper limb (UL) paralysis. Among the 14 BB muscles assessed, Se was 85.6% (83.6-87.4%); Sp was 89.7% (88.6-90.7%), and overall Acc was 88.5% (87.6-89.4%) and ranged between 78.6% and 98.7%. The presence of IMA was detected correctly in all patients. These results support the algorithm's use for in-field IMA assessment based on data acquired with wearable sensors. The assessment and monitoring of IMA in acute and subacute patients with UMNL could improve the quality of care needed by triggering early treatments to lessen long-term complications.

Associations between muscle morphology and spasticity in children with spastic cerebral palsy

INTRODUCTION

Due to the heterogeneous clinical presentation of spastic cerebral palsy (SCP), which makes spasticity treatment challenging, more insight into the complex interaction between spasticity and altered muscle morphology is warranted.

AIMS

We studied associations between spasticity and muscle morphology and compared muscle morphology between commonly observed spasticity patterns (i.e. different muscle activation patterns during passive stretches).

METHODS

Spasticity and muscle morphology of the medial gastrocnemius (MG) and semitendinosus (ST) were defined in 74 children with SCP (median age 8 years 2 months, GMFCS I/II/III: 31/25/18, bilateral/unilateral: 46/27). Using an instrumented assessment, spasticity was quantified as the difference in muscle activation recorded during passive stretches at low and high velocities and was classified in mixed length-/velocity-dependent or pure velocity-dependent activation patterns. Three-dimensional freehand ultrasound was used to assess muscle morphology (volume and length) and echogenicity intensity (as a proxy for muscle quality). Spearman correlations and Mann-Whitney-U tests defined associations and group differences, respectively.

RESULTS

A moderate negative association (r = -0.624, p < 0.001) was found between spasticity and MG muscle volume, while other significant associations between spasticity and muscle morphology parameters were weak. Smaller normalized muscle volume (MG p = 0.004, ST p=<0.001) and reduced muscle belly length (ST p = 0.015) were found in muscles with mixed length-/velocity-dependent patterns compared to muscles with pure velocity-dependent patterns.

DISCUSSION

Higher spasticity levels were associated with smaller MG and ST volumes and shorter MG muscles. These muscle morphology alterations were more pronounced in muscles that activated during low-velocity stretches compared to muscles that only activated during high-velocity stretches.

Motor performance, motor impairments, and quality of life after eccentric resistance training in neurological populations: A systematic review and meta-analyses

BACKGROUND

Many overlapping factors impair motor performance and quality of life in neurological patients. Eccentric resistance training (ET) has potential benefits for improving motor performance and treating motor impairments better than some traditional rehabilitation approaches.

OBJECTIVE

To estimate the effect of ET in neurological settings.

METHODS

Seven databases were reviewed up to May 2022 according to PRSIMA guidelines to find randomized clinical trials involving adults with a neurological condition, who underwent ET as set by the American College of Sports Medicine. Motor performance (main outcome) was assessed as strength, power and capacities during activity. Secondary outcomes (impairments) were muscle structure, flexibility, muscle activity, tone, tremor, balance and fatigue. Tertiary outcomes were risk of fall, and self-reports of quality of life.

RESULTS

Ten trials were included, assessed using Risk of Bias 2.0 tool, and used to compute meta-analyses. Effective effects in favour of ET were found for strength and power, but not for capacities during activity. Mixed results were found for secondary and tertiary outcomes.

CONCLUSION

ET may be a promising intervention to better improve strength/power in neurological patients. More studies are needed to improve the quality of evidence underlying changes responsible for these results.

New insights into acupuncture techniques for poststroke spasticity

With the trend of aging population getting more obvious, stroke has already been a major public health problem worldwide. As a main disabling motor impairment after stroke, spasticity has unexpected negative impacts on the quality of life and social participation in patients. Moreover, it brings heavy economic burden to the family and society. Previous researches indicated that abnormality of neural modulation and muscle property corelates with the pathogenesis of poststroke spasticity (PSS). So far, there still lacks golden standardized treatment regimen for PSS; furthermore, certain potential adverse-events of the mainstream therapy, for example, drug-induced generalized muscle weakness or high risk related surgery somehow decrease patient preference and compliance, which brings challenges to disease treatment and follow-up care. As an essential non-pharmacological therapy, acupuncture has long been used for PSS in China and shows favorable effects on improvements of spastic hypertonia and motor function. Notably, previous studies focused mainly on the research of antispastic acupoints. In comparison, few studies lay special stress on the other significant factor impacting on acupuncture efficacy, that is acupuncture technique. Based on current evidences from the clinic and laboratory, we will discuss certain new insights into acupuncture technique, in particular the antispastic needling technique, for PSS management in light of its potential effects on central modulations as well as peripheral adjustments, and attempt to provide some suggestions for future studies with respect to the intervention timing and course, application of acupuncture techniques, acupoint selection, predictive and aggravating factors of PSS, aiming at optimization of antispastic acupuncture regimen and improvement of quality of life in stroke patients. More innovations including rigorous study design, valid objective assessments for spasticity, and related experimental studies are worthy to be expected in the years ahead.

Clinical efficacy of botulinum toxin type A in patients with traumatic brain injury, spinal cord injury, or multiple sclerosis: An observational longitudinal study

Botulinum toxin type A (BoNT-A) is the treatment of choice for focal spasticity, with a concomitant effect on pain reduction and improvement of quality of life (QoL). Current evidence of its efficacy is based mainly on post stroke spasticity. This study aims to clarify the role of BoNT-A in the context of non-stroke spasticity (NSS). We enrolled 86 patients affected by multiple sclerosis, spinal cord injury, and traumatic brain injury with clinical indication to perform BoNT-A treatment. Subjects were evaluated before injection and after 1, 3, and 6 months. At every visit, spasticity severity using the modified Ashworth scale, pain using the numeric rating scale, QoL using the Euro Qol Group EQ-5D-5L, and the perceived treatment effect using the Global Assessment of Efficacy scale were recorded. In our population BoNT-A demonstrated to have a significant effect in improving all the outcome variables, with different effect persistence over time in relation to the diagnosis and the number of treated sites. Our results support BoNT-A as a modifier of the disability condition and suggest its implementation in the treatment of NSS, delivering a possible starting point to generate diagnosis-specific follow-up programs.

Clinical trial identifier

NCT04673240.

Revising the stretch reflex threshold method to measure stretch hyperreflexia in cerebral palsy

Hyper-resistance is an increased resistance to passive muscle stretch, a common feature in neurological disorders. Stretch hyperreflexia, an exaggerated stretch reflex response, is the neural velocity-dependent component of hyper-resistance, and has been quantitatively measured using the stretch reflex threshold (i.e., joint angle at the stretch reflex electromyographic onset). In this study, we introduce a correction in how the stretch reflex threshold is calculated, by accounting for the stretch reflex latency (i.e., time between the stretch reflex onset at the muscle spindles and its appearance in the electromyographic signal). Furthermore, we evaluated how this correction affects the stretch reflex threshold in children and young adults with spastic cerebral palsy. A motor-driven ankle dynamometer induced passive ankle dorsiflexions at four incremental velocities in 13 children with cerebral palsy (mean age: 13.5 years, eight males). The stretch reflex threshold for soleus and medial gastrocnemius muscles was calculated as 1) the joint angle corresponding to the stretch reflex electromyographic onset (i.e., original method); and as 2) the joint angle corresponding to the electromyographic onset minus the individual Hoffmann-reflex latency (i.e., latency corrected method). The group linear regression slopes between stretch velocity and stretch reflex threshold differed in both muscles between methods (p < 0.05). While the original stretch reflex threshold was velocity dependent in both muscles (p < 0.05), the latency correction rendered it velocity independent. Thus, the effects of latency correction on the stretch reflex threshold are substantial, especially at higher stretch velocities, and should be considered in future studies.

Dry needling for the treatment of muscle spasticity in a patient with multiple sclerosis: a case report

BACKGROUND

Spasticity is a common cause of disability in multiple sclerosis (MS), which can negatively affect the patient's walking and balance.

OBJECTIVE

To evaluate the immediate effect of dry needling (DN) on spasticity and mobility in a female with MS.

CASE DESCRIPTION

In this case, a 38-year-old female with a 4-year history of MS was treated. The hamstring muscles (biceps femoris and semitendinosus) were needled for 1 minute in a single session. The main outcome measures were the Modified Modified Ashworth Scale (MMAS) to evaluate spasticity, the Timed 25-Foot Walk (T25FW) for the assessment of mobility and leg function performance, and stiffness as a biomechanical index of spasticity measured by a dynamometer. The assessments were done before and immediately after DN.

OUTCOMES

The MMAS scores decreased in the hamstrings (1 to 0) and quadriceps (2 to 1). The mobility improved as the time for T25FW decreased from 16.30 to 9.29 seconds. The stiffness of hamstring decreased after treatment (0.451 to 0.312).

CONCLUSION

One session of DN for the hamstring muscle decreased spasticity and improved mobility in this patient with MS. Further studies are suggested.

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

Background

Muscle overactivity is one of the positive signs of upper motor neuron lesions. In these patients, the loss of muscle length and extensibility resulting from soft tissue rearrangement has been suggested as a contributing cause of muscle overactivity in response to stretching.

Objective

To assess the effects of surgical lengthening of the quadriceps femoris (QF) muscle-tendon unit by aponeurectomy on muscle spasticity.

Methods

This is a case-control study on chronic stroke patients with hemiparesis that have undergone lower limb functional surgery over a 8-year period. CASEs underwent corrective surgery for both the foot and knee deviations, inclusive of a QF aponeurectomy. Controls (CTRLs) underwent corrective surgery for foot deviations only. QF spasticity was assessed with the Modified Tardieu Scale (MTS) before and 1 month after surgery. The Wilcoxon test was used to assess MTS variations over time and the Mann–Whitney test was used to verify the presence of group differences at the 1 month mark.

Results

Ninety-three patients were included: 57 cases (30F, 1–34 years from lesion) and 36 controls (12F, 1–35 years from lesion). Before surgery, both CASEs and CTRLs had similar MTS scores (median MTS = 3) and functional characteristics. One month after surgery, QF spasticity was significantly lower in the CASEs compared to CTRLs (p = 0.033) due to a significant reduction of the median MTS score from 3 to 0 in the CASE group (p < 0.001) and no variations in the CTRL group (p = 0.468). About half of the cases attained clinically significant MTS reductions and complete symptom relief even many years from the stroke.

Conclusions

Functional surgery inclusive of QF aponeurectomy can be effective in reducing or suppressing spasticity in chronic stroke patients. This is possibly a result of the reduction in neuromuscular spindle activation due to a decrease in muscle shortening, passive tension, and stiffness.

Changes in intermuscular connectivity during active elbow extension reveal a functional simplification of motor control after stroke

Background

Stroke alters muscle co-activation and notably leads to exaggerated antagonist co-contraction responsible for impaired motor function. However, the mechanisms underlying this exaggerated antagonist co-contraction remain unclear. To fill this gap, the analysis of oscillatory synchronicity in electromyographic signals from synergistic muscles, also called intermuscular coherence, was a relevant tool.

Objective

This study compares functional intermuscular connectivity between muscle pairs of the paretic and non-paretic upper limbs of stroke subjects and the dominant limb of control subjects, concomitantly between two muscle pairs with a different functional role, through an intermuscular coherence analysis.

Methods

Twenty-four chronic stroke subjects and twenty-four healthy control subjects were included. Subjects performed twenty elbow extensions while kinematic data and electromyographic activity of both flexor and extensor elbow muscles were recorded. Intermuscular coherence was analyzed in the beta frequency band compared to the assessment of antagonist co-contraction.

Results

Intermuscular coherence was higher in the stroke subjects’ paretic limbs compared to control subjects. For stroke subjects, the intermuscular coherence of the antagonist-antagonist muscle pair (biceps brachii—brachioradialis) was higher than that of the agonist-antagonist muscle pair (triceps brachii—brachioradialis). For the paretic limb, intermuscular coherence of the antagonist-antagonist muscle pair presented a negative relationship with antagonist co-contraction.

Conclusion

Differences in intermuscular coherence between the paretic limbs of stroke subjects and control subjects suggest a higher common central drive during movement. Furthermore, results highlight the association between stroke-related alteration of intermuscular functional connectivity and the alteration of motor function.

Patterns of asymmetry and energy cost generated from predictive simulations of hemiparetic gait

Hemiparesis, defined as unilateral muscle weakness, often occurs in people post-stroke or people with cerebral palsy, however it is difficult to understand how this hemiparesis affects movement patterns as it often presents alongside a variety of other neuromuscular impairments. Predictive musculoskeletal modeling presents an opportunity to investigate how impairments affect gait performance assuming a particular cost function. Here, we use predictive simulation to quantify the spatiotemporal asymmetries and changes to metabolic cost that emerge when muscle strength is unilaterally reduced and how reducing spatiotemporal symmetry affects metabolic cost. We modified a 2-D musculoskeletal model by uniformly reducing the peak isometric muscle force unilaterally. We then solved optimal control simulations of walking across a range of speeds by minimizing the sum of the cubed muscle excitations. Lastly, we ran additional optimizations to test if reducing spatiotemporal asymmetry would result in an increase in metabolic cost. Our results showed that the magnitude and direction of effort-optimal spatiotemporal asymmetries depends on both the gait speed and level of weakness. Also, the optimal speed was 1.25 m/s for the symmetrical and 20% weakness models but slower (1.00 m/s) for the 40% and 60% weakness models, suggesting that hemiparesis can account for a portion of the slower gait speed seen in people with hemiparesis. Modifying the cost function to minimize spatiotemporal asymmetry resulted in small increases (~4%) in metabolic cost. Overall, our results indicate that spatiotemporal asymmetry may be optimal for people with hemiparesis. Additionally, the effect of speed and the level of weakness on spatiotemporal asymmetry may help explain the well-known heterogenous distribution of spatiotemporal asymmetries observed in the clinic. Future work could extend our results by testing the effects of other neuromuscular impairments on optimal gait strategies, and therefore build a more comprehensive understanding of the gait patterns observed in clinical populations.

Brachial plexus birth injury and cerebral palsy lead to a common contracture phenotype characterized by reduced functional muscle length and strength

Introduction

Brachial plexus birth injury (BPBI) and cerebral palsy (CP) both cause disabling contractures for which no curative treatments exist, largely because contracture pathophysiology is incompletely understood. The distinct neurologic nature of BPBI and CP suggest different potential contracture etiologies, although imbalanced muscle strength and insufficient muscle length have been variably implicated. The current study directly compares the muscle phenotype of elbow flexion contractures in human subjects with BPBI and CP to test the hypothesis that both conditions cause contractures characterized by a deficit in muscle length rather than an excess in muscle strength.

Methods

Subjects over 6 years of age with unilateral BPBI or hemiplegic CP, and with elbow flexion contractures greater than 10 degrees on the affected side, underwent bilateral elbow flexion isokinetic strength testing to identify peak torque and impulse, or area under the torque-angle curve. Subjects then underwent needle microendoscopic sarcomere length measurement of bilateral biceps brachii muscles at symmetric joint angles.

Results

In five subjects with unilateral BPBI and five with hemiplegic CP, peak torque and impulse were significantly lower on the affected versus unaffected sides, with no differences between BPBI and CP subjects in the percent reduction of either strength measurement. In both BPBI and CP, the percent reduction of impulse was significantly greater than that of peak torque, consistent with functionally shorter muscles. Similarly, in both conditions, affected muscles had significantly longer sarcomeres than unaffected muscles at symmetric joint angles, indicating fewer sarcomeres in series, with no differences between BPBI and CP subjects in relative sarcomere overstretch.

Discussion

The current study reveals a common phenotype of muscle contracture in BPBI and CP, with contractures in both conditions characterized by a similar deficit in muscle length rather than an excess in muscle strength. These findings support contracture treatments that lengthen rather than weaken affected muscles. Moreover, the discovery of a common contracture phenotype between CP and BPBI challenges the presumed dichotomy between upper and lower motor neuron lesions in contracture pathogenesis, instead revealing the broader concept of “myobrevopathy”, or disorder of short muscle, warranting increased investigation into the poorly understood mechanisms regulating muscle length.

Validation of a semiological maneuver for the evaluation of spastic dynamic clubfoot: an approach based on the judgment of experts in physical medicine and rehabilitation

BACKGROUND

The evaluation of spasticity of the plantar flexors in dynamic clubfoot is difficult due to the almost invariable concomitance of Achilles clonus, which is a semiological artifact. No description was found in the literature of a technique for inhibiting or reducing the discharge generated by Achilles clonus to allow a correct assessment of spasticity in this segment.

AIM

Validation of a semiological maneuver that reduces or eliminates Achilles clonus for the adequate evaluation of spastic dynamic clubfoot.

DESIGN

Multicenter cross-sectional study.

SETTING

The study was conducted by 12 experts in physical medicine and rehabilitation from various clinics and hospitals in Colombia.

POPULATION

Thirty-five adults with dynamic spastic clubfoot and Achilles clonus secondary to upper motor neuron syndrome who attended outpatient consultation at physical medicine and rehabilitation services in eight cities Colombia from August 2020 to February 2021.

METHODS

The usual method for examining spastic plantar flexors was compared to the proposed semiological maneuver to evaluate the proposed maneuver contributed to the reduction or elimination of Achilles clonus to allow a more accurate measure of spasticity in this segment. Four dimensions were evaluated by the experts: time required for application, simplicity, effectiveness and clinical utility. A cutoff point was established to identify whether the maneuver was unacceptable, acceptable or excellent.

RESULTS

The application of the maneuver was able to reduce or eliminate Achilles clonus as a masking sign of spasticity in the plantar flexors in 100% of the patients and was considered excellent in 77.1% of the cases for the four dimensions evaluated. A decrease in the degree of spasticity of the plantar flexors was observed when the maneuver was applied.

CONCLUSIONS

The proposed maneuver reduces or eliminates Achilles clonus, which could allow a more precise evaluation of spasticity in this segment. All of the experts recommended including the maneuver in routine examinations of this population.

CLINICAL REHABILITATION IMPACT

Applying the proposed maneuver could improve the selection of patients with spastic dynamic clubfoot who require specific treatment.

Respective Contributions of Instrumented 3D Gait Analysis Data and Tibial Motor Nerve Block on Presurgical Spastic Equinus Foot Assessment: A Retrospective Study of 40 Adults

Spastic equinus foot is a common deformity in neurologic patients who compromise walking ability. It is related to the imbalance between weak dorsiflexion and overactive plantar flexor muscles. To achieve the best functional results after surgical management, the challenge is to identify the relevant components involved in the deformity using several methods, namely, examination in the supine position, motor nerve blocks allowing transient anesthesia of suspected overactive muscles, and kinematic and electromyographic data collected during an instrumented 3D gait analysis. The procedure is not standardized; its use varies from one team to another. Access to gait analysis laboratories is limited, and some teams do not perform motor nerve blocks. When both examinations are available, instrumental data from the instrumented 3D gait analysis can be used to specify muscle targets for motor blocks, but data collected from both examinations are sometimes considered redundant. This retrospective cohort analysis compared examination in the supine position, temporary motor nerve blocks, and instrumented 3D gait analysis data in 40 adults after brain or spinal cord injuries. Clinical data collected before motor nerve block was not associated with instrumental data to assess calf muscle's overactivity and tibialis anterior function. Improvement of ankle dorsiflexion in the swing phase after tibial motor nerve block was associated with soleus spastic co-contraction during this phase corroborating its involvement in ankle dorsiflexion defects. This study showed the relevance of tibial motor nerve block to remove spastic calf dystonia and facilitate the assessment of calf contracture. It also underlined the need for complementary and specific analyses of the tibialis anterior abnormal activation pattern after motor nerve block to confirm or deny their pathological nature.

Shared and distinct voxel-based lesion-symptom mappings for spasticity and impaired movement in the hemiparetic upper limb

Hemiparesis and spasticity are common co-occurring manifestations of hemispheric stroke. The relationship between impaired precision and force in voluntary movement (hemiparesis) and the increment in muscle tone that stems from dysregulated activity of the stretch reflex (spasticity) is far from clear. Here we aimed to elucidate whether variation in lesion topography affects hemiparesis and spasticity in a similar or dis-similar manner. Voxel-based lesion-symptom mapping (VLSM) was used to assess the impact of lesion topography on (a) upper limb paresis, as reflected by the Fugl-Meyer Assessment scale for the upper limb and (b) elbow flexor spasticity, as reflected by the Tonic Stretch Reflex Threshold, in 41 patients with first-ever stroke. Hemiparesis and spasticity were affected by damage to peri-Sylvian cortical and subcortical regions and the putamen. Hemiparesis (but not spasticity) was affected by damage to the corticospinal tract at corona-radiata and capsular levels, and by damage to white-matter association tracts and additional regions in the temporal cortex and pallidum. VLSM conjunction analysis showed only a minor overlap of brain voxels where the existence of damage affected both hemiparesis and spasticity, suggesting that control of voluntary movement and regulation of muscle tone at rest involve largely separate parts of the motor network.

Effects of dry needling on muscle spasticity of the upper limb in a survivor of traumatic brain injury: a case report

Background

Survivors of moderate and severe traumatic brain injury typically present with spasticity, an upper motor neuron lesion associated with hyperexcitability of the stretch reflex due to disinhibition of cortical influences on spinal cord circuits and structural and functional changes in skeletal muscle. There is growing evidence supporting the effectiveness of dry needling in abating spasticity.

Case presentation

The present case aims to quantify the effects of dry needling on upper limb spastic muscles in a survivor of severe traumatic brain injury in a 27-year-old Iranian man. The treated muscles were biceps brachii, brachialis, flexor digitorum superficialis and profundus, flexor carpi radialis, flexor carpi ulnaris, opponens pollicis, and adductor pollicis. Outcome measures were evaluated before and 1 hour after the intervention. Our results showed that the patient’s upper limb recovery stage and hand function improved one grade according to Brunnstrom recovery stages. Spasticity assessed using the Modified Modified Ashworth Scale in all movements showed one-grade abatement, except in the forearm pronator. Passive resistance force decreased in all movements except in forearm supination. Active range of motion and passive range of motion increased in all movements except in active and passive forearm supination. Hand dexterity improved in both affected and unaffected hands.

Conclusions

Results shown that dry needling could be a favorable option for reducing spasticity.