Botulinum toxin type A combined with neurodynamic mobilization for upper limb spasticity after stroke: a case report

Acute effects of a single neurodynamic mobilization session on range of motion and H-reflex in asymptomatic young subjects: A controlled study

Neurodynamic techniques have yielded good clinical results in the treatment of various pathologies. The objective of this study is to examine the short-term effects of neurodynamic techniques of the sciatic nerve on hip ROM (range of motion) and on the amplitude and latency of the soleus H-reflex and M-waves, in young asymptomatic subjects. In a double-blind controlled trial design, 60 young asymptomatic participants were randomly assigned into six groups with different levels of manipulation of the sciatic nerve. The passive straight leg raise test was used to evaluate the hip ROM amplitude. All evaluations were performed before, 1 min after, and 30 min after intervention. For each time-point, spinal and muscle excitability were also tested. ROM increased in all groups, but none of the treatment groups had superior effects than the group with no treatment. This means that ROM testing maneuvers increased ROM amplitude, with no add-on effect of the proposed neurodynamic techniques. Neurophysiological responses changed similarly in all groups, showing that the aftereffects were not intervention-specific. We observed a significant negative association between the change in limb temperature and the change in latencies of all potentials. ROM-testing procedures performed repeatedly increase ROM amplitude. This observation should be considered when evaluating the aftereffects of therapeutic interventions on ROM amplitude. None of the explored neurodynamic techniques produced acute aftereffects on hip ROM amplitude, spinal or muscle excitability different to the induced by the ROM testing maneuver.

Effectiveness of Neurodynamic Interventions in Patients With Stroke: Protocol for a Systematic Review and Meta-analysis

Background

Stroke is the most common and serious neurological condition, which can lead to death, limited functionality, and reduced quality of life. Studies with conflicting results and various methodological limitations have been conducted to assess the effectiveness of neurodynamic interventions for patients with stroke.

Objective

This systematic review and meta-analysis aimed to investigate the pooled effectiveness of different neurodynamic interventions on patients with stroke.

Methods

The PubMed, PEDro, and Google Scholar databases will be searched for studies published with full text in the English language from inception to date. Randomized controlled trials evaluating the effect of different neurodynamic techniques on patients with stroke will be included. The primary outcome measures will include pain, disability/function, and quality of life. Secondary outcome measures will include physical performance measures such as balance, range of motion, muscle strength, and specific diagnostic and neurodynamic test outcomes. The screening, data extraction, and methodological quality assessment will be performed by two independent reviewers. The PEDro scale will be used to systematically appraise the methodological quality. Review Manager V.5.4 software will be used for statistical analysis. Weighted mean difference or standardized mean difference with 95% CIs and P values will be used to calculate the treatment effect for each outcome variable.

Results

Search terms and search databases have been identified. The data extraction sheet has also been developed. This study is expected to be completed by the end of 2022.

Conclusions

This study will provide up-to-date evidence on the effectiveness and use of neurodynamic interventions for patients with stroke in clinical practice.

Trial Registration

PROSPERO CRD42022319972; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=319972

International Registered Report Identifier (IRRID)

PRR1-10.2196/38956

Spasticity and Range of Motion Over Time in Stroke Patients Who Received Multiple-Dose Botulinum Toxin Therapy

OBJECTIVE

This study examined how the effects of botulinum toxin therapy changed over time by sequential evaluation of clinical improvements in spasticity and contracture in 24 chronic-stage stroke patients on repeated botulinum toxin therapy who were receiving fewer rehabilitation interventions.

METHODS

Botulinum toxin injection was administered into the spastic muscle of the paralyzed upper or lower limb 5 times with at least 3-month intervals. Modified Ashworth Scale and range of motion were measured before and 2 weeks after each dose in the extremities to compare the first measurement value with subsequent values. Each predose value was also compared with the first predose value.

RESULTS

Compared with predose scores, Modified Ashworth Scale significantly improved in all flexors after 2 weeks from the first to fifth doses. Range of motion significantly improved in wrist dorsiflexion and ankle dorsiflexion. Comparison of values before each dose versus the first predose value showed significant improvement both in the Modified Ashworth Scale score of wrist flexors, finger flexors, and ankle planter flexors, and the range of motion of elbow extension, wrist dorsiflexion, and ankle dorsiflexion.

CONCLUSION

The comparison of predose values versus 2-week postdose values indicated that the effect of botulinum toxin formulation would not lessen after repeated injections with continuous improvements of Modified Ashworth Scale and range of motion. The comparison of predose values versus the first predose value also suggested that multiple injections of botulinum toxin formulation could be more effective in reducing spasticity and increasing the range of motion than a single injection.

The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Objectives To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01; P<.001) and pain (intensity [0-10]: mean difference, -1.78; 95% CI: -2.55, -1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, -1.89; 95% CI: -3.14, -0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593-615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117.

Manual therapy and neurodynamic mobilization in a patient with peroneal nerve paralysis: a case report

OBJECTIVE

The purpose of this case report is to describe a therapeutic intervention for peroneal nerve paralysis involving the sciatic nerve.

CLINICAL FEATURES

A 24-year-old man presented with peroneal nerve paralysis with decreased sensation, severe pain in the popliteal fossa, and steppage gait, which occurred 3 days prior to the consultation. Magnetic resonance imaging and electromyography confirmed lumbar disk herniation with sciatic common peroneal nerve entrapment in the popliteal fossa.

INTERVENTION AND OUTCOME

A combined treatment protocol of spinal and fibular head manipulation and neurodynamic mobilization including soft tissue work of the psoas and hamstring muscles was performed. Outcome measures were assessed at pretreatment, 1 week posttreatment, and 3-month follow-up and included numeric pain rating scale, range of motion, pressure pain threshold, and manual muscle testing. Treatment interventions were applied for 3 sessions over a period of 1 week. Results showed reduction of the patient's subjective pain and considerable improvement in range of motion, strength, and sensation in his left foot, which was restored to full function.

CONCLUSION

A combined program of spinal and fibular head manipulation and neurodynamic mobilization reduced pain, increased range of motion and strength, and restored full function to the left leg in this patient who had severe functional impairment related to a compressed left common peroneal nerve.

Botulinum toxin type A combined with neurodynamic mobilization for lower limb spasticity: a case report

OBJECTIVE

This case report describes a patient with severe lower limb spasticity treated with botulinum toxin type A (BoNT-A) and neurodynamic mobilization (NM).

CLINICAL FEATURES

An 81-year-old male patient presented with a severe spastic lower limbs after total right hip replacement and severe alcoholic polyneuropathy. After the right hip replacement, he presented with generalized spasticity, crouched posture, and a large sacral pressure sore. The severe spasticity in his knees prevented walking.

INTERVENTION AND OUTCOME

The patient underwent combined treatment with BoNT-A and NM of the lower limb in 4 weekly applications. Evaluations were performed pretreatment, 4 weeks after the injection, and at a follow-up session 9 months after finishing treatment. We measured the following outcomes: pain by the Numerical Rating Scale, spasticity by the Modified Ashworth Scale for Grading Spasticity, acceptance and emotional reaction to the treatment by the Hospital Anxiety and Depression Scale, and functionality by ranges of motion. We found that the patient improved in all of the outcomes after treatment, and these results were maintained during the follow-up. After treatment, the patient was able to improve wound healing by properly positioning himself in bed or on his wheelchair and walking with help. At the follow-up evaluation, the results were maintained. The patient showed good acceptance and decreased anxiety/depression after treatment.

CONCLUSION

For this patient, the combination of NM and BoNT-A treatment decreased pain and spasticity and improved joint ranges of motion.

Botulinum toxin type A combined with cervical spine manual therapy for masseteric hypertrophy in a patient with Alzheimer-type dementia: a case report

OBJECTIVE

The purpose of this case study is to present the findings of combining botulinum toxin type A (BoNT-A) and cervical spine manual therapy to address masseter muscle spasticity in a patient with Alzheimer-type dementia.

CASE REPORT

A 78-year-old woman with bilateral spasticity of the masseteric regions for 2 years was referred for physiotherapy. She had trismus and bruxism, and could neither close nor open her mouth normally; thus, she was unable to be fed orally in a normal manner.

INTERVENTION AND OUTCOME

The patient underwent combined treatment with BoNT-A and cervical spine manual therapy. A medical physician (neurologist) performed the BoNT-A injections into 2 points at the center of the lower third of the masseter muscle. A physical therapist performed manual therapy interventions targeted at the cervical spine. Manual therapy started the day after the BoNT-A injection and continued for 5 sessions per week for a total period of 2 weeks. Clinical outcomes were measured including spasticity (Modified Ashworth Scale), functionality (Barthel Index), and jaw opening. Outcomes were conducted at baseline, 2 weeks after treatment, and at 2-month follow-up session after finishing the treatment. The patient improved in all of the outcomes at the end of treatment, and these results were maintained during the follow-up. After treatment, the patient was able to feed with minimal caregiver dependency because oral feeding was possible.

CONCLUSION

The patient in this study responded positively to a combination of BoNT-A and manual therapy, resulting in decreased masseter muscles spasticity and improved trismus and bruxism.