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

IMPROVE study protocol, investigating post-stroke local muscle vibrations to promote cerebral plasticity and functional recovery: a single-blind randomised controlled trial

INTRODUCTION

Spasticity is a frequent disabling consequence following a stroke. Local muscle vibrations (LMVs) have been proposed as a treatment to address this problem. However, little is known about their clinical and neurophysiological impacts when used repeatedly during the subacute phase post-stroke. This project aims to evaluate the effects of a 6-week LMV protocol on the paretic limb on spasticity development in a post-stroke subacute population.

METHODS AND ANALYSIS

This is an interventional, controlled, randomised, single-blind (patient) trial. 100 participants over 18 years old will be recruited, within 6 weeks following a first stroke with hemiparesis or hemiplegia. All participants will receive a conventional rehabilitation programme, plus 18 sessions of LMV (ie, continuously for 30 min) on relaxed wrist and elbow flexors: either (1) at 80 Hz for the interventional group or (2) at 40 Hz plus a foam band between the skin and the device for the control group.Participants will be evaluated at baseline, at 3 weeks and 6 weeks, and at 6 months after the end of the intervention. Spasticity will be measured by the modified Ashworth scale and with an isokinetic dynamometer. Sensorimotor function will be assessed with the Fugl-Meyer assessment of the upper extremity. Corticospinal and spinal excitabilities will be measured each time.

ETHICS AND DISSEMINATION

This study was recorded in a clinical trial and obtained approval from the institutional review board (Comité de protection des personnes Ile de France IV, 2021-A03219-32). All participants will be required to provide informed consent. The results of this trial will be published in peer-reviewed journals to disseminate information to clinicians and impact their practice for an improved patient's care.

TRIAL REGISTRATION NUMBER

Clinical Trial: NCT05315726 DATASET: EUDRAct.

Effects of neurorehabilitation with and without dry needling technique on muscle thickness, reflex torque, spasticity and functional performance in chronic ischemic stroke patients with spastic upper extremity muscles: a blinded randomized sham-controlled clinical trial

PURPOSE

Evaluation the effects of dry needling on sonographic, biomechanical and functional parameters of spastic upper extremity muscles.

METHODS

Twenty-four patients (35-65 years) with spastic hand were randomly allocated into two equal groups: intervention and sham-controlled groups. The treatment protocol was 12-sessions neurorehabilitation for both groups and 4-sessions dry needling or sham-needling for the intervention group and sham-controlled group respectively on wrist and fingers flexor muscles. The outcomes were muscle thickness, spasticity, upper extremity motor function, hand dexterity and reflex torque which were assessed before, after the 12th session, and after one-month follow-up by a blinded assessor.

RESULTS

The analysis showed that there was a significant reduction in muscle thickness, spasticity and reflex torque and a significant increment in motor function and dexterity in both groups after treatment (p < 0.01). However, these changes were significantly higher in the intervention group (p < 0.01) except for spasticity. Moreover, a significant improvement was seen in all outcomes measured one-month after the end of the treatment in the intervention group (p < 0.01).

CONCLUSIONS

Dry needling plus neurorehabilitation could decrease muscle thickness, spasticity and reflex torque and improve upper-extremity motor performance and dexterity in chronic stroke patients. These changes were lasted one-month after treatment.Trial Registration Number: IRCT20200904048609N1IMPLICATION FOR REHABILITATIONUpper extremity spasticity is one of the stroke consequences which interfere with motor function and dexterity of patient hand in activity of daily livingApplying the dry needling accompanied with neurorehabilitation program in post-stroke patients with muscle spasticity can reduce the muscle thickness, spasticity and reflex torque and improve upper extremity functions.

Using sEMG Signal Frequency to Evaluate Post-Stroke Elbow Spasticity

Spasticity is a motor disorder with high prevalence and critical consequences following a stroke. Reliable and sensitive measurements are important to guide the selection and evaluation of treatment strategies. Technology-assisted methods, such as the surface electromyography (sEMG) technique, have been developed to measure spasticity as sensitive and accurate alternatives to commonly used clinical scales. However, sEMG amplitude based measures may confound spasticity-induced muscle activities with other types of muscle contractions. This study thus introduces the idea of using sEMG frequency information to detect spasticity as a potential solution to overcome the limitations of existing sEMG based measures. The preliminary results of three patients demonstrate the possibility and future research directions for this approach.

Validity and reliability of the assessment of hand flexors stiffness using a new electromechanical oscillatory device in people with stroke

Hyper-resistance after a central nervous system injury has been largely referred to as spasticity, which is but one of its neural components. Assessment largely relies on clinical scales (Modified Ashworth scale - MAS and Modified Tardieu scale, MTS) which are unable to distinguish between the non-neural (tissue-related) and the neural (central nervous system-related) components. This study assessed criterion validity and reliability (reproducibility) of muscle stiffness measures, namely, maximum elastic stiffness (ELmax), viscous stiffness (VI), and path length (L-path) in the hand flexor muscles among people with stroke. Measurements were obtained with a wrist-electromechanical oscillatory device (w-EOD). Twenty-four people with arm impairment after stroke were evaluated with the w-EOD and clinical assessment (MAS and MTS), twice on the same day (short-term reliability) and once 10 days later (long-term reliability). For criterion validity, a Spearman coefficient ( r ) was calculated between stiffness values and the clinical scales. For reliability, intraclass correlation coefficients (ICCs), SEM, and MDC95 were calculated. Moderate correlations were observed between EL max and MAS ( r  = 0.49) and MTS (V2, r  = 0.43; V3, r  = 0.49) of the wrist flexors, and finger flexors (MAS, r  = 0.60; MTS V2, r  = 0.56; MTS V3, r  = 0.55). There was a poor correlation between the clinical scales and VI and L-path. Reliability was excellent for all stiffness measurements at short term (EL max : 0.95, VI: 0.94, L-path: 0.92) and good at long term (EL max : 0.87, VI: 0.76, L-path: 0.82). In conclusion, stiffness measurements are valid and reliable to evaluate hyper-resistance in people with stroke.

Technology-assisted assessment of spasticity: a systematic review

BACKGROUND

Spasticity is defined as "a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks". It is a highly prevalent condition following stroke and other neurological conditions. Clinical assessment of spasticity relies predominantly on manual, non-instrumented, clinical scales. Technology based solutions have been developed in the last decades to offer more specific, sensitive and accurate alternatives but no consensus exists on these different approaches.

METHOD

A systematic review of literature of technology-based methods aiming at the assessment of spasticity was performed. The approaches taken in the studies were classified based on the method used as well as their outcome measures. The psychometric properties and usability of the methods and outcome measures reported were evaluated.

RESULTS

124 studies were included in the analysis. 78 different outcome measures were identified, among which seven were used in more than 10 different studies each. The different methods rely on a wide range of different equipment (from robotic systems to simple goniometers) affecting their cost and usability. Studies equivalently applied to the lower and upper limbs (48% and 52%, respectively). A majority of studies applied to a stroke population (N = 79). More than half the papers did not report thoroughly the psychometric properties of the measures. Analysis identified that only 54 studies used measures specific to spasticity. Repeatability and discriminant validity were found to be of good quality in respectively 25 and 42 studies but were most often not evaluated (N = 95 and N = 78). Clinical validity was commonly assessed only against clinical scales (N = 33). Sensitivity of the measure was assessed in only three studies.

CONCLUSION

The development of a large diversity of assessment approaches appears to be done at the expense of their careful evaluation. Still, among the well validated approaches, the ones based on manual stretching and measuring a muscle activity reaction and the ones leveraging controlled stretches while isolating the stretch-reflex torque component appear as the two promising practical alternatives to clinical scales. These methods should be further evaluated, including on their sensitivity, to fully inform on their potential.

A Practical Post-Stroke Elbow Spasticity Assessment Using an Upper Limb Rehabilitation Robot: A Validation Study

Spasticity is a motor disorder characterised by a velocity-dependent increase in muscle tone, which is critical in neurorehabilitation given its high prevalence and potential negative influence among the post-stroke population. Accurate measurement of spasticity is important as it guides the strategy of spasticity treatment and evaluates the effectiveness of spasticity management. However, spasticity is commonly measured using clinical scales which may lack objectivity and reliability. Although many technology-assisted measures have been developed, showing their potential as accurate and reliable alternatives to standard clinical scales, they have not been widely adopted in clinical practice due to their low usability and feasibility. This paper thus introduces an easy-to-use robotic based measure of elbow spasticity and its evaluation protocol. Preliminary results collected with one post-stroke patient and one healthy control subject are presented and demonstrate the feasibility of the approach.

Evaluating Viscoelastic Properties of the Wrist Joint During External Perturbations: Influence of Velocity, Grip, and Handedness

In this study, we designed a robot-based method to compute a mechanical impedance model that could extract the viscoelastic properties of the wrist joint. Thirteen subjects participated in the experiment, testing both dominant and nondominant hands. Specifically, the robotic device delivered position-controlled disturbances in the flexion-extension degree of freedom of the wrist. The external perturbations were characterized by small amplitudes and fast velocities, causing rotation at the wrist joint. The viscoelastic characteristics of the mechanical impedance of the joint were evaluated from the wrist kinematics and corresponding torques. Since the protocol used position inputs to determine changes in mean wrist torque, a detailed analysis of wrist joint dynamics could be made. The scientific question was whether and how these mechanical features changed with various grip demands and perturbation velocities. Nine experimental conditions were tested for each hand, given by the combination of three velocity perturbations (fast, medium, and slow) and three hand grip conditions [self-selected grip, medium and high grip force, as percentage of the maximum voluntary contraction (MVC)]. Throughout the experiments, electromyographic signals of the extensor carpi radialis (ECR) and the flexor carpi radialis (FCR) were recorded. The novelty of this work included a custom-made soft grip sensor, wrapped around the robotic handle, to accurately quantify the grip force exerted by the subjects during experimentation. Damping parameters were in the range of measurements from prior studies and consistent among the different experimental conditions. Stiffness was independent of both direction and velocity of perturbations and increased with increasing grip demand. Both damping and stiffness were not different between the dominant and nondominant hands. These results are crucial to improving our knowledge of the mechanical characteristics of the wrist, and how grip demands influence these properties. This study is the foundation for future work on how mechanical characteristics of the wrist are affected in pathological conditions.

Effect of inhibitory kinesiotaping on spasticity in patients with chronic stroke: a randomized controlled pilot trial

BACKGROUND

There is no consensus regarding the positive effect of kinesiotaping (KT) on spasticity. All previous studies have measured spasticity by Modified Ashworth Scale (MAS) scale which is a subjective clinical assessment.

OBJECTIVE

To investigate the effect of inhibitory KT on the spasticity of plantar flexor muscles using both Hoffmann-reflex (H-reflex) and MAS scale. H-reflex is a neurophysiological technique that objectively evaluates spasticity by reflecting the excitability of motor neurons.

METHODS

Thirty patients were randomly assigned into inhibitory KT (n = 15) and control (n = 15) groups. The inhibitory KT group received KT from insertion to the origin of gastrocsoleus muscle . Spasticity was assessed at baseline and 30 min and 48 h after taping by H-reflex and MAS scale. The control group received no taping and spasticity was assessed at baseline and 30 min and 48 h after the baseline.

RESULT

There was a significant time × group effect for the maximal peak-to-peak amplitude of the H_max/M_max ratio (p = .007), indicating that H_max/M_max ratio decreased significantly after 48 h in the inhibitory KT in comparison with the baseline (P = .001) and 30 min after-intervention (p = .002); meanwhile, it did not change significantly in the control group (P > .05). However, none of the groups showed a statistically significant change in MAS score (P > .05).

CONCLUSIONS

Application of inhibitory KT was found to be able to reduce the H_max/M_max ratio in patients with stroke. As a result, inhibitory KT could have beneficial effects on spasticity.