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Verduzco-Gutierrez M, Raghavan P, Pruente J, Moon D, List CM, Hornyak JE, Gul F, Deshpande S, Biffl S, Al Lawati Z, Alfaro A. AAPM&R consensus guidance on spasticity assessment and management. PM R 2024; 16:864-887. [PMID: 38770827 DOI: 10.1002/pmrj.13211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/19/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care. OBJECTIVE To develop consensus-based practice recommendations to identify and address gaps in spasticity care. METHODS The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations. RESULTS The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity. CONCLUSION This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.
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Affiliation(s)
- Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation and Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Pruente
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Moon
- Department of Physical Medicine and Rehabilitation, Jefferson Moss-Magee Rehabilitation Hospital, Elkins Park, Pennsylvania, USA
| | | | - Joseph Edward Hornyak
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatma Gul
- Department of Physical Medicine and Rehabilitation Department, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Supreet Deshpande
- Department of Pediatric Rehabilitation Medicine, Gillette Children's Hospital, St.Paul, Minnesota, USA
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Susan Biffl
- Division Pediatric Rehabilitation Medicine Department of Orthopedic Surgery, UCSD Rady Children's Hospital, San Diego, California, USA
| | - Zainab Al Lawati
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abraham Alfaro
- Rehabilitation Medicine, AtlantiCare Health Services, Inc., Federally Qualified Health Center (FQHC), Atlantic City, New Jersey, USA
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Vacchiano V, Bonan L, Liguori R, Rizzo G. Primary Lateral Sclerosis: An Overview. J Clin Med 2024; 13:578. [PMID: 38276084 PMCID: PMC10816328 DOI: 10.3390/jcm13020578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Primary lateral sclerosis (PLS) is a rare neurodegenerative disorder which causes the selective deterioration of the upper motor neurons (UMNs), sparing the lower motor neuron (LMN) system. The clinical course is defined by a progressive motor disability due to muscle spasticity which typically involves lower extremities and bulbar muscles. Although classically considered a sporadic disease, some familiar cases and possible causative genes have been reported. Despite it having been recognized as a rare but distinct entity, whether it actually represents an extreme end of the motor neuron diseases continuum is still an open issue. The main knowledge gap is the lack of specific biomarkers to improve the clinical diagnostic accuracy. Indeed, the diagnostic imprecision, together with some uncertainty about overlap with UMN-predominant ALS and Hereditary Spastic Paraplegia (HSP), has become an obstacle to the development of specific therapeutic trials. In this study, we provided a comprehensive analysis of the existing literature, including neuropathological, clinical, neuroimaging, and neurophysiological features of the disease, and highlighting the controversies still unsolved in the differential diagnoses and the current diagnostic criteria. We also discussed the current knowledge gaps still present in both diagnostic and therapeutic fields when approaching this rare condition.
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Affiliation(s)
- Veria Vacchiano
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, 40139 Bologna, Italy; (V.V.); (R.L.)
| | - Luigi Bonan
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy;
| | - Rocco Liguori
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, 40139 Bologna, Italy; (V.V.); (R.L.)
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy;
| | - Giovanni Rizzo
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, 40139 Bologna, Italy; (V.V.); (R.L.)
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Perpetuini D, Russo EF, Cardone D, Palmieri R, De Giacomo A, Intiso D, Pellicano F, Pellegrino R, Merla A, Calabrò RS, Filoni S. Assessing the Impact of Electrosuit Therapy on Cerebral Palsy: A Study on the Users' Satisfaction and Potential Efficacy. Brain Sci 2023; 13:1491. [PMID: 37891858 PMCID: PMC10605024 DOI: 10.3390/brainsci13101491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
The aim of this study is to evaluate the effectiveness of electrosuit therapy in the clinical treatment of children with Cerebral Palsy, focusing on the effect of the therapy on spasticity and trunk control. Moreover, the compliance of caregivers with respect to the use of the tool was investigated. During the period ranging from 2019 to 2022, a total of 26 children (18 M and 8 F), clinically stable and affected by CP and attending the Neurorehabilitation Unit of the "Padre Pio Foundation and Rehabilitation Centers", were enrolled in this study. A subset of 12 patients bought or rented the device; thus, they received the administration of the EMS-based therapy for one month, whereas the others received only one-hour training to evaluate the feasibility (by the caregivers) and short-term effects. The Gross Motor Function Classification System was utilized to evaluate gross motor functions and to classify the study sample, while the MAS and the LSS were employed to assess the outcomes of the EMS-based therapy. Moreover, between 80% and 90% of the study sample were satisfied with the safety, ease of use, comfort, adjustment, and after-sales service. Following a single session of electrical stimulation with EMS, patients exhibited a statistically significant enhancement in trunk control. For those who continued this study, the subscale of the QUEST with the best score was adaptability (0.74 ± 0.85), followed by competence (0.67 ± 0.70) and self-esteem (0.59 ± 0.60). This study investigates the impact of the employment of the EMS on CP children's ability to maintain trunk control. Specifically, after undergoing a single EMS session, LSS showed a discernible improvement in children's trunk control. In addition, the QUEST and the PIADS questionnaires demonstrated a good acceptability and satisfaction of the garment by the patients and the caregivers.
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Affiliation(s)
- David Perpetuini
- Department of Engineering and Geology, University G. D’Annunzio of Chieti-Pescara, 65127 Pescara, Italy; (D.P.); (D.C.); (A.M.)
| | - Emanuele Francesco Russo
- Padre Pio Foundation and Rehabilitation Centers, 71013 San Giovanni Rotondo, Italy; (E.F.R.); (F.P.)
| | - Daniela Cardone
- Department of Engineering and Geology, University G. D’Annunzio of Chieti-Pescara, 65127 Pescara, Italy; (D.P.); (D.C.); (A.M.)
| | - Roberta Palmieri
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (R.P.); (A.D.G.)
| | - Andrea De Giacomo
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (R.P.); (A.D.G.)
| | - Domenico Intiso
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (D.I.); (S.F.)
| | - Federica Pellicano
- Padre Pio Foundation and Rehabilitation Centers, 71013 San Giovanni Rotondo, Italy; (E.F.R.); (F.P.)
| | - Raffaello Pellegrino
- Department of Scientific Research, Campus Ludes, Off-Campus Semmelweis University, 6912 Lugano, Switzerland;
| | - Arcangelo Merla
- Department of Engineering and Geology, University G. D’Annunzio of Chieti-Pescara, 65127 Pescara, Italy; (D.P.); (D.C.); (A.M.)
| | | | - Serena Filoni
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy; (D.I.); (S.F.)
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Campanini I, Bò MC, Bassi MC, Damiano B, Scaltriti S, Lusuardi M, Merlo A. Outcome measures for assessing the effectiveness of physiotherapy interventions on equinus foot deformity in post-stroke patients with triceps surae spasticity: A scoping review. PLoS One 2023; 18:e0287220. [PMID: 37824499 PMCID: PMC10569611 DOI: 10.1371/journal.pone.0287220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/01/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE Equinus foot deformity (EFD) is the most common deviation after stroke. Several physiotherapy interventions have been suggested to treat it. However, studies evaluating the efficacy of these treatments vary widely in terms of assessment modalities, type of data analysis, and nomenclature. This scoping review aimed to map current available evidence on outcome measures and the modalities employed to assess the effectiveness of physiotherapy programs for the reduction of triceps surae (TS) spasticity and EFD in patients with stroke. METHODS Scoping review methodological frameworks have been used. Three databases were investigated. Primary literature addressing TS spasticity in adult patients with stroke using physiotherapy interventions was included. Findings were systematically summarized in tables according to the intervention used, intervention dosage, control group, clinical, and instrumental outcome measures. RESULTS Of the 642 retrieved studies, 53 papers were included. TS spasticity was assessed by manual maneuvers performed by clinicians (mainly using the Ashworth Scale), functional tests, mechanical evaluation through robotic devices, or instrumental analysis and imaging (such as the torque-angle ratio, the H-reflex, and ultrasound images). A thorough critical appraisal of the construct validity of the scales and of the statistics employed was provided, particularly focusing on the choice of parametric and non-parametric approaches when using ordinal scales. Finally, the complexity surrounding the concept of "spasticity" and the possibility of assessing the several underlying active and passive causes of EFD, with a consequent bespoke treatment for each of them, was discussed. CONCLUSION This scoping review provides a comprehensive description of all outcome measures and assessment modalities used in literature to assess the effectiveness of physiotherapy treatments, when used for the reduction of TS spasticity and EFD in patients with stroke. Clinicians and researchers can find an easy-to-consult summary that can support both their clinical and research activities.
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Affiliation(s)
- Isabella Campanini
- Neuromotor and Rehabilitation Department, LAM–Motion Analysis Laboratory, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Correggio, Italy
| | - Maria Chiara Bò
- Neuromotor and Rehabilitation Department, LAM–Motion Analysis Laboratory, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Correggio, Italy
- Merlo Bioengineering, Parma, Italy
| | | | - Benedetta Damiano
- Neuromotor and Rehabilitation Department, LAM–Motion Analysis Laboratory, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Correggio, Italy
| | - Sara Scaltriti
- Neuromotor and Rehabilitation Department, LAM–Motion Analysis Laboratory, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Correggio, Italy
| | - Mirco Lusuardi
- Neuromotor and Rehabilitation Department, Azienda USL-IRCCS Reggio Emilia, Correggio, Italy
| | - Andrea Merlo
- Neuromotor and Rehabilitation Department, LAM–Motion Analysis Laboratory, San Sebastiano Hospital, Azienda USL-IRCCS di Reggio Emilia, Correggio (Reggio Emilia), Correggio, Italy
- Merlo Bioengineering, Parma, Italy
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Ellerbusch CL, Chapple KM, Seibert JB. A case series in individuals with multiple sclerosis using direct current electrical stimulation to inhibit spasticity and improve functional outcomes. Mult Scler J Exp Transl Clin 2023; 9:20552173231186512. [PMID: 37465424 PMCID: PMC10350763 DOI: 10.1177/20552173231186512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/20/2023] Open
Abstract
Background and Purpose Multiple sclerosis (MS) has a high incidence of debilitating spasticity. Central Nervous System (CNS) intrafusal settings have an impact on spasticity level. Mechanoreceptors of the Peripheral Nervous System (PNS) communicate monosynaptically with the central nervous system (CNS). This case series assesses feasibility of multimodal treatment of individuals with MS using a direct current electrical stimulation (DC) to influence mechanoreceptors. Case Description and Intervention Seven MS diagnosed participants with Expanded Disability Status Scale (EDSS) = 6.0-8.0 completed 18 visits over 6 weeks of using DC combined with neuromuscular reeducation. Design included pre-, post- outcome measures of EDSS, 12-item MS Walking Scale (MSWS-12), Range of Motion (ROM), Manual Muscle Testing (MMT), Modified Ashworth Test (MAT), Timed 25-Foot walk (T25WT), Timed Up and Go (TUG) and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Outcome 125 out of a possible 126 visits were completed, demonstrating a high level of tolerance. Individual results included trends towards improvement in spasticity and agonists. Discussion This case series design of seven heterogenous subjects with MS is a low sample size for statistical analysis and should be considered a pilot. The study demonstrates a high level of feasibility and possible correlations to consider. Further research is warranted.
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Affiliation(s)
| | - Kristina M Chapple
- Department of Surgery, University of Arizona School of Medicine, Phoenix, Arizona, USA
| | - Julie B Seibert
- Multiple Sclerosis, Overseeing Neurologist, Littleton, Colorado, USA
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Perpetuini D, Russo EF, Cardone D, Palmieri R, De Giacomo A, Pellegrino R, Merla A, Calabrò RS, Filoni S. Use and Effectiveness of Electrosuit in Neurological Disorders: A Systematic Review with Clinical Implications. Bioengineering (Basel) 2023; 10:680. [PMID: 37370612 DOI: 10.3390/bioengineering10060680] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Electrical stimulation through surface electrodes is a non-invasive therapeutic technique used to improve voluntary motor control and reduce pain and spasticity in patients with central nervous system injuries. The Exopulse Mollii Suit (EMS) is a non-invasive full-body suit with integrated electrodes designed for self-administered electrical stimulation to reduce spasticity and promote flexibility. The EMS has been evaluated in several clinical trials with positive findings, indicating its potential in rehabilitation. This review investigates the effectiveness of the EMS for rehabilitation and its acceptability by patients. The literature was collected through several databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Positive effects of the garment on improving motor functions and reducing spasticity have been shown to be related to the duration of the administration period and to the dosage of the treatment, which, in turn, depend on the individual's condition and the treatment goals. Moreover, patients reported wellbeing during stimulation and a muscle-relaxing effect on the affected limb. Although additional research is required to determine the efficacy of this device, the reviewed literature highlights the EMS potential to improve the motor capabilities of neurological patients in clinical practice.
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Affiliation(s)
- David Perpetuini
- Department of Engineering and Geology, University G. D'Annunzio of Chieti-Pescara, 65127 Pescara, Italy
| | | | - Daniela Cardone
- Department of Engineering and Geology, University G. D'Annunzio of Chieti-Pescara, 65127 Pescara, Italy
| | - Roberta Palmieri
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Andrea De Giacomo
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Raffaello Pellegrino
- Department of Scientific Research, Campus Ludes, Off-Campus Semmelweis University, 6912 Lugano, Switzerland
| | - Arcangelo Merla
- Department of Engineering and Geology, University G. D'Annunzio of Chieti-Pescara, 65127 Pescara, Italy
| | | | - Serena Filoni
- Padre Pio Foundation and Rehabilitation Centers, 71013 San Giovanni Rotondo, Italy
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Fallahi MS, Azadnajafabad S, Maroufi SF, Pour-Rashidi A, Khorasanizadeh M, Sattari SA, Faramarzi S, Slavin KV. Application of Vagus Nerve Stimulation in Spinal Cord Injury Rehabilitation. World Neurosurg 2023; 174:11-24. [PMID: 36858292 DOI: 10.1016/j.wneu.2023.02.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
Spinal cord injury (SCI) is a prevalent devastating condition causing significant morbidity and mortality, especially in developing countries. The pathophysiology of SCI involves ischemia, neuroinflammation, cell death, and scar formation. Due to the lack of definitive therapy for SCI, interventions mainly focus on rehabilitation to reduce deterioration and improve the patient's quality of life. Currently, rehabilitative exercises and neuromodulation methods such as functional electrical stimulation, epidural electrical stimulation, and transcutaneous electrical nerve stimulation are being tested in patients with SCI. Other spinal stimulation techniques are being developed and tested in animal models. However, often these methods require complex surgical procedures and solely focus on motor function. Vagus nerve stimulation (VNS) is currently used in patients with epilepsy, depression, and migraine and is being investigated for its application in other disorders. In animal models of SCI, VNS significantly improved locomotor function by ameliorating inflammation and improving plasticity, suggesting its use in human subjects. SCI patients also suffer from nonmotor complications, including pain, gastrointestinal dysfunction, cardiovascular disorders, and chronic conditions such as obesity and diabetes. VNS has shown promising results in alleviating these conditions in non-SCI patients, which makes it a possible therapeutic option in SCI patients.
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Affiliation(s)
- Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Azadnajafabad
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Pour-Rashidi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran; Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York, New York, USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sina Faramarzi
- School of Biological Sciences, University of California, Irvine, Irvine, California, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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Massey S, Vanhoestenberghe A, Duffell L. Neurophysiological and clinical outcome measures of the impact of electrical stimulation on spasticity in spinal cord injury: Systematic review and meta-analysis. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:1058663. [PMID: 36589715 PMCID: PMC9801305 DOI: 10.3389/fresc.2022.1058663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022]
Abstract
This systematic review and meta-analysis aims to determine whether non-invasive electrical stimulation (ES) is effective at reducing spasticity in people living with spinal cord injury (SCI). PubMed, Web of Science, Scopus and Cochrane Central Register of Controlled Trials databases were searched in April 2022. Primary outcome measures were the Ashworth scale (AS), Modified Ashworth scale (MAS), Pendulum test and the Penn spasm frequency scale (PSFS). Secondary outcomes were the Hoffman (H)- reflex, motor-evoked potentials (MEPs) and posterior-root reflexes (PRRs). A random-effects model, using two correlation coefficients, ( C o r r = 0.1 , C o r r = 0.2 ) determined the difference between baseline and post-intervention measures for RCTs. A quantitative synthesis amalgamated data from studies with no control group (non-RCTs). Twenty-nine studies were included: five in the meta-analysis and 17 in the amalgamation of non-RCT studies. Twenty studies measured MAS or AS scores, 14 used the Pendulum test and one used the PSFS. Four measured the H-reflex and no studies used MEPs or PRRs. Types of ES used were: transcutaneous electrical nerve stimulation (TENS), transcutaneous spinal cord stimulation (TSCS), functional electrical stimulation (FES) cycling and FES gait. Meta-analyses of 3 studies using the MAS and 2 using the Pendulum test were carried out. For MAS scores, non-invasive ES was effective at reducing spasticity compared to a control group (p = 0.01, C o r r = 0.1 ; p = 0.002, C o r r = 0.2 ). For Pendulum test outcomes, there was no statistically significant difference between intervention and control groups. Quantitative synthesis of non-RCT studies revealed that 22 of the 29 studies reported improvement in at least one measure of spasticity following non-invasive ES, 13 of which were statistically significant (p < 0.05). Activation of the muscle was not necessary to reduce spasticity. Non-invasive ES can reduce spasticity in people with SCI, according to MAS scores, for both RCT and non-RCT studies, and Pendulum test values in non-RCT studies. This review could not correlate between clinical and neurophysiological outcomes; we recommend the additional use of neurophysiological outcomes for future studies. The use of TSCS and TENS, which did not induce a muscle contraction, indicate that activation of afferent fibres is at least required for non-invasive ES to reduce spasticity.
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Affiliation(s)
- Sarah Massey
- Aspire Centre for Rehabilitation Engineering and Assistive Technologies, Division of Surgery and Interventional Sciences, University College London, London, United Kingdom,Department of Medical Physics & Biomedical Engineering, University College London, London, United Kingdom,Correspondence: Sarah Massey
| | - Anne Vanhoestenberghe
- Department of Medical Physics & Biomedical Engineering, University College London, London, United Kingdom,School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | - Lynsey Duffell
- Aspire Centre for Rehabilitation Engineering and Assistive Technologies, Division of Surgery and Interventional Sciences, University College London, London, United Kingdom,Department of Medical Physics & Biomedical Engineering, University College London, London, United Kingdom
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9
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Neurorehabilitation in Multiple Sclerosis-A Review of Present Approaches and Future Considerations. J Clin Med 2022; 11:jcm11237003. [PMID: 36498578 PMCID: PMC9739865 DOI: 10.3390/jcm11237003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Multiple sclerosis is an increasingly prevalent disease, representing the leading cause of non-traumatic neurological disease in Europe and North America. The most common symptoms include gait deficits, balance and coordination impairments, fatigue, spasticity, dysphagia and an overactive bladder. Neurorehabilitation therapeutic approaches aim to alleviate symptoms and improve the quality of life through promoting positive immunological transformations and neuroplasticity. The purpose of this study is to evaluate the current treatments for the most debilitating symptoms in multiple sclerosis, identify areas for future improvement, and provide a reference guide for practitioners in the field. It analyzes the most cited procedures currently in use for the management of a number of symptoms affecting the majority of patients with multiple sclerosis, from different training routines to cognitive rehabilitation and therapies using physical agents, such as electrostimulation, hydrotherapy, cryotherapy and electromagnetic fields. Furthermore, it investigates the quality of evidence for the aforementioned therapies and the different tests applied in practice to assess their utility. Lastly, the study looks at potential future candidates for the treatment and evaluation of patients with multiple sclerosis and the supposed benefits they could bring in clinical settings.
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10
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Logosu D, Tagoe TA, Adjei P. Transcutaneous electrical nerve stimulation in the management of calf muscle spasticity in cerebral palsy: A pilot study. IBRO Neurosci Rep 2021; 11:194-199. [PMID: 34939065 PMCID: PMC8664700 DOI: 10.1016/j.ibneur.2021.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/28/2021] [Indexed: 11/25/2022] Open
Abstract
This study sets out to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in the management of calf muscle spasticity in children with cerebral palsy. The study follows a one group pre-test–post-test design involving fifteen children with spastic cerebral palsy, presenting with calf muscle spasticity. Spasticity was assessed before and after a 30 min application of TENS to the bilateral calf muscles. The H-reflex (electromyography) of the calf muscles and Modified Ashworth Scale (MAS) served as a measure of spasticity. A goniometer was used to measure the range of motion (ROM) angles for ankle dorsiflexion. We report here no significant difference (p > 0.05) between the left and right H-reflex responses, MAS scores, and ROM scores recorded at baseline (pre-test). Correlation analysis show no correlation (p > 0.05) between the pre-test HA Max (maximum H-reflex amplitude)/MA Max (maximum M-Wave Amplitude) ratio and MAS scores of both the left and right calf muscles. However, TENS significantly reduced (p < 0.05) the HA of the left calf muscle and MAS scores of the left and right calf muscles. Additionally, TENS significantly increased the ROM scores of the left and right calf muscles. Our findings lend support to existing evidence that TENS is effective in reducing spasticity. The potential mechanism underlying this effect is a reduction in neuron excitability. The application of TENS in children with spastic Cerebral palsy is well tolerated. H-reflex is an effective tool in measuring spasticity objectively. TENS may be effective as an adjunct treatment option in the management of spasticity.
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Affiliation(s)
- Delali Logosu
- Department of Physiology, University of Ghana, Accra, Ghana
| | - Thomas A Tagoe
- Department of Physiology, University of Ghana, Accra, Ghana
| | - Patrick Adjei
- Department of Medicine and Therapeutics, University of Ghana, Accra, Ghana.,Department of Medicine and Therapeutics, Korle-Bu Teaching Hospital, Accra, Ghana
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11
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Pennati GV, Bergling H, Carment L, Borg J, Lindberg PG, Palmcrantz S. Effects of 60 Min Electrostimulation With the EXOPULSE Mollii Suit on Objective Signs of Spasticity. Front Neurol 2021; 12:706610. [PMID: 34721255 PMCID: PMC8554021 DOI: 10.3389/fneur.2021.706610] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The EXOPULSE Mollii method is an innovative full-body suit approach for non-invasive electrical stimulation, primarily designed to reduce disabling spasticity and improve motor function through the mechanism of reciprocal inhibition. This study aimed to evaluate the effectiveness of one session of stimulation with the EXOPULSE Mollii suit at different stimulation frequencies on objective signs of spasticity and clinical measures, and the subjective perceptions of the intervention. Methods: Twenty patients in the chronic phase after stroke were enrolled in a cross-over, double-blind controlled study. Electrical stimulation delivered through EXOPULSE Mollii was applied for 60 min at two active frequencies (20 and 30 Hz) and in OFF-settings (placebo) in a randomized order, every second day. Spasticity was assessed with controlled-velocity passive muscle stretches using the NeuroFlexor hand and foot modules. Surface electromyography (EMG) for characterizing flexor carpi radialis, medial gastrocnemius, and soleus muscles activation, Modified Ashworth Scale and range of motion were used as complementary tests. Finally, a questionnaire was used to assess the participants' perceptions of using the EXOPULSE Mollii suit. Results: At group level, analyses showed no significant effect of stimulation at any frequency on NeuroFlexor neural component (NC) and EMG amplitude in the upper or lower extremities (p > 0.35). Nevertheless, the effect was highly variable at the individual level, with eight patients exhibiting reduced NC (>1 N) in the upper extremity after stimulation at 30 Hz, 5 at 20 Hz and 3 in OFF settings. All these patients presented severe spasticity at baseline, i.e., NC > 8 N. Modified Ashworth ratings of spasticity and range of motion did not change significantly after stimulation at any frequency. Finally, 75% of participants reported an overall feeling of well-being during stimulation, with 25% patients describing a muscle-relaxing effect on the affected hand and/or foot at both 20 and 30 Hz. Conclusions: The 60 min of electrical stimulation with EXOPULSE Mollii suit did not reduce spasticity consistently in the upper and lower extremities in the chronic phase after stroke. Findings suggest a need for further studies in patients with severe spasticity after stroke including repeated stimulation sessions. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT04076878, identifier: NCT04076878.
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Affiliation(s)
- Gaia Valentina Pennati
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Hanna Bergling
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Loïc Carment
- Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Université de Paris, Paris, France
| | - Jörgen Borg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Påvel G Lindberg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden.,Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Université de Paris, Paris, France
| | - Susanne Palmcrantz
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
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12
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Biktimirov A, Pak O, Bryukhovetskiy I, Sharma A, Sharma HS. Neuromodulation as a basic platform for neuroprotection and repair after spinal cord injury. PROGRESS IN BRAIN RESEARCH 2021; 266:269-300. [PMID: 34689861 DOI: 10.1016/bs.pbr.2021.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Spinal cord injury (SCI) is one of the most challenging medical issues. Spasticity is a major complication of SCI. A combination of spinal cord stimulation, new methods of neuroprotection and biomedical cellular products provides fundamentally new options for SCI treatment and rehabilitation. The paper attempts to critically analyze the effectiveness of using these procedures for patients with SCI, suggesting a protocol for a step-by-step personalized treatment of SCI, based on continuity of modern conservative and surgical methods. The study argues the possibility of using neuromodulation as a basis for rehabilitating patients with SCI.
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Affiliation(s)
- Artur Biktimirov
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia.
| | - Oleg Pak
- Department of Neurosurgery, Medical Center, Far Eastern Federal University, Vladivostok, Russia
| | - Igor Bryukhovetskiy
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Paley CA, Wittkopf PG, Jones G, Johnson MI. Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1060. [PMID: 34684097 PMCID: PMC8539683 DOI: 10.3390/medicina57101060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 12/11/2022]
Abstract
Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.
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Affiliation(s)
- Carole A. Paley
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
- Research and Development Department, Airedale National Health Service (NHS) Foundation Trust, Skipton Road, Steeton, Keighley BD20 6TD, UK
| | - Priscilla G. Wittkopf
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| | - Gareth Jones
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| | - Mark I. Johnson
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
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14
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Johnson MI. Resolving Long-Standing Uncertainty about the Clinical Efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) to Relieve Pain: A Comprehensive Review of Factors Influencing Outcome. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:378. [PMID: 33919821 PMCID: PMC8070828 DOI: 10.3390/medicina57040378] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/18/2021] [Accepted: 04/12/2021] [Indexed: 12/26/2022]
Abstract
Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to 'electrically rubbing pain away'. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the 'efficacy-impasse'. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a 'run-in phase' to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings.
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Affiliation(s)
- Mark I Johnson
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK
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15
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Hedin H, Wong C, Sjödén A. The effects of using an electrodress (Mollii®) to reduce spasticity and enhance functioning in children with cerebral palsy: a pilot study. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2020. [DOI: 10.1080/21679169.2020.1807602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Christian Wong
- Orthopaedic Department, Hvidovre Hospital, Hvidovre, Denmark
| | - Ann Sjödén
- Orthopaedics and Spasticity Treatment at the Neuropediatric Clinic, Falun Hospital, Sweden
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16
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Palmcrantz S, Pennati GV, Bergling H, Borg J. Feasibility and potential effects of using the electro-dress Mollii on spasticity and functioning in chronic stroke. J Neuroeng Rehabil 2020; 17:109. [PMID: 32778118 PMCID: PMC7419224 DOI: 10.1186/s12984-020-00740-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Spasticity after lesions of central motor pathways may be disabling and there is a need for new, cost-effective treatment methods. One novel approach is offered by the electro-dress Mollii®, primarily designed to enhance reciprocal inhibition of spastic muscles by multifocal, transcutaneous antagonist stimulation. Methods The Mollii® suit was set individually for 20 participants living with spasticity and hemiplegia after stroke and used in the home setting for 6 weeks. Usability and perceived effects were monitored by weekly telephone interviews. Outcome was assessed by use of the NeuroFlexor™ method for quantification of the neural component (NC) of resistance to passive stretch (spasticity), and the modified Ashworth scale (MAS) for total resistance, Fugl-Meyer Assessment of motor recovery for sensorimotor function in upper (FM-UE) and lower extremities (FM-LE), activity performance with the Action Research Arm Test (ARAT), Berg balance scale, 10 m and 6 min walk tests, and perceived functioning with the Stroke Impact Scale. Results Compliance was high (mean 19.25 of 21 sessions). Perceived positive effects were reported by 60% and most commonly related to decreased muscle tone (n = 9), improved gait pattern function (n = 7) and voluntary movement in the upper extremity (n = 6). On a group level, the NC decreased significantly in the wrist flexors of the affected hand (p = 0.023) and significant improvements according to FM-UE (p = 0.000) and FM-LE (p = 0.003) were seen after the intervention. No significant difference was detected with MAS or assessed activity performance, except for the ARAT (p = 0.000). FM-UE score change correlated significantly and fairly with the perceived effect in the upper extremity (r 0.498 p = 0.025) and in the corresponding analysis for the FM-LE and perceived effect in the lower extremity (r = 0.469 p = 0.037). Conclusion This study indicates that the Mollii® method is feasible when used in the home setting to decrease spasticity and improve sensorimotor function. The results may guide a larger controlled study combined with rehabilitation interventions to enhance effects on activity and participation domains. Trial registration NCT04076878. Registered 2 September 2019 - Retrospectively registered
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Affiliation(s)
- Susanne Palmcrantz
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden.
| | - Gaia Valentina Pennati
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
| | - Hanna Bergling
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
| | - Jörgen Borg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
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17
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Hon AJ, Kraus P. Spasticity Management After Spinal Cord Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00280-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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18
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Duffell LD, Donaldson NDN. A Comparison of FES and SCS for Neuroplastic Recovery After SCI: Historical Perspectives and Future Directions. Front Neurol 2020; 11:607. [PMID: 32714270 PMCID: PMC7344227 DOI: 10.3389/fneur.2020.00607] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
There is increasing evidence that neuroplastic changes can occur even years after spinal cord injury, leading to reduced disability and better health which should reduce the cost of healthcare. In motor-incomplete spinal cord injury, recovery of leg function may occur if repetitive training causes afferent input to the lumbar spinal cord. The afferent input may be due to activity-based therapy without electrical stimulation but we present evidence that it is faster with electrical stimulation. This may be spinal cord stimulation or peripheral nerve stimulation. Recovery is faster if the stimulation is phasic and that the patient is trying to use their legs during the training. All the published studies are small, so all conclusions are provisional, but it appears that patients with more disability (AIS A and B) may need to continue using stimulation and for them, an implanted stimulator is likely to be convenient. Patients with less disability (AIS C and D) may make useful recovery and improve their quality of life from a course of therapy. This might be locomotion therapy but we argue that cycling with electrical stimulation, which uses biofeedback to encourage descending drive, causes rapid recovery and might be used with little supervision at home, making it much less expensive. Such an electrical therapy followed by conventional physiotherapy might be affordable for the many people living with chronic SCI. To put this in perspective, we present some information about what treatments are funded in the UK and the US.
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Affiliation(s)
- Lynsey D Duffell
- Implanted Devices Group, University College London, London, United Kingdom.,Aspire CREATe, University College London, London, United Kingdom
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19
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Ip AH, Phadke CP, Boulias C, Ismail F, Mills PB. Practice Patterns of Physicians Using Adjunct Therapies with Botulinum Toxin Injection for Spasticity: A Canadian Multicenter Cross-Sectional Survey. PM R 2020; 13:372-378. [PMID: 32578339 DOI: 10.1002/pmrj.12442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/05/2020] [Accepted: 06/13/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. OBJECTIVE To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. DESIGN Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. SETTING Not applicable. PARTICIPANTS Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. RESULTS Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P < .05). Research priorities included determining the effectiveness of immediate postinjection application of adjunct therapies (eg, injected muscle activation with ES or stretching) and nutraceuticals. CONCLUSIONS Canadian physicians frequently use adjunct therapies in combination with BoNT injection to treat spasticity. Financial and time constraints are identified as barriers to implementation of adjunct therapies that are currently supported by research, and patient preferences may also affect compliance. Future research should focus on adjunct therapies that overcome these barriers.
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Affiliation(s)
- Alvin H Ip
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chetan P Phadke
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Chris Boulias
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Farooq Ismail
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Patricia B Mills
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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20
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Parker J, Powell L, Mawson S. Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review. J Med Internet Res 2020; 22:e15981. [PMID: 31913131 PMCID: PMC6996755 DOI: 10.2196/15981] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness. OBJECTIVE This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors. METHODS Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs. RESULTS In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P≤.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years. CONCLUSIONS This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery. TRIAL REGISTRATION PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715.
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21
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Ferrer Pastor M, Iñigo Huarte V, Juste Díaz J, Goiri Noguera D, Sogues Colom A, Cerezo Durá M. [Systematic review of the treatment of spasticity in acquired adult brain damage]. Rehabilitacion (Madr) 2020; 54:51-62. [PMID: 32007183 DOI: 10.1016/j.rh.2019.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/12/2019] [Accepted: 06/25/2019] [Indexed: 10/25/2022]
Abstract
Spasticity is a motor disorder characterised by an increase in muscle tone that appears as a consequence of a central nervous system disorder, leading to deficit and disability and impairing quality of life. In acquired adult brain damage, spasticity is a severe and frequent problem, appearing in 20-30% of patients with stroke and in 13-20% of patients with moderate-severe traumatic brain injury. The main objective of this study was to perform a systematic review of the treatments used in spasticity in adult patients with acquired brain damage secondary to stroke and head trauma. A systematic search of randomised controlled trials, published between January 1, 2013 and June 30, 2017 in English and Spanish, was carried out in the PubMed, Cochrane plus Library and Ovid databases. We finally selected 17 studies, with methodological quality that was at least acceptable according to the Jadad scale. The most frequently investigated treatments are botulinum toxin, especially serotype A, together with rehabilitative measures. Clinical scales are the most frequently used to assess spasticity.
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Affiliation(s)
- M Ferrer Pastor
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España.
| | - V Iñigo Huarte
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J Juste Díaz
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - D Goiri Noguera
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Sogues Colom
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - M Cerezo Durá
- Servicio de Medicina Física y Rehabilitación, Consorcio Hospital General Universitario de Valencia, Valencia, España
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22
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Hutson TH, Di Giovanni S. The translational landscape in spinal cord injury: focus on neuroplasticity and regeneration. Nat Rev Neurol 2019; 15:732-745. [DOI: 10.1038/s41582-019-0280-3] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2019] [Indexed: 12/22/2022]
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23
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Effectiveness of Physiotherapy Interventions on Spasticity in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil 2019; 97:793-807. [PMID: 29794531 DOI: 10.1097/phm.0000000000000970] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of the study was to examine the effectiveness of physiotherapy (PT) interventions on spasticity in people with multiple sclerosis. DESIGN A systematic search was performed using PRISMA guidance. Studies evaluate the effect of PT interventions on spasticity were included. People with multiple sclerosis, spasticity, disability and PT interventions characteristics were extracted in included studies. Level of evidence was synthesized by the Grade of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses were performed by calculating Hedges g at 95% confidence interval. RESULTS A total of 29 studies were included in the review, and 25 were included in the meta-analyses. The included PT interventions were exercise therapy, electrical stimulation, radial shock wave therapy, vibration, and standing. The review and meta-analyses showed different evidences of benefits and nonbenefits for PT interventions on some spasticity outcomes. The best quality evidences were for beneficial effects of exercise therapy especially robot gait training and outpatient exercise programs on self-perceived spasticity and muscle tone respectively. The review results were positive regarding the acute effects, follow-up measurements, safety, progressive MS, and nonambulatory people with multiple sclerosis. The included articles were heterogeneous and badly reported in PT interventions and people with multiple sclerosis characteristics. CONCLUSIONS Physiotherapy interventions can be a safe and beneficial option for spasticity in people with multiple sclerosis. No firm conclusion can be drawn on overall spasticity. Further researches in different spasticity aspects are needed.
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24
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Hofstoetter US, Freundl B, Danner SM, Krenn MJ, Mayr W, Binder H, Minassian K. Transcutaneous Spinal Cord Stimulation Induces Temporary Attenuation of Spasticity in Individuals with Spinal Cord Injury. J Neurotrauma 2019; 37:481-493. [PMID: 31333064 DOI: 10.1089/neu.2019.6588] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Epidural spinal cord stimulation (SCS) is currently regarded as a breakthrough procedure for enabling movement after spinal cord injury (SCI), yet one of its original applications was for spinal spasticity. An emergent method that activates similar target neural structures non-invasively is transcutaneous SCS. Its clinical value for spasticity control would depend on inducing carry-over effects, because the surface-electrode-based approach cannot be applied chronically. We evaluated single-session effects of transcutaneous lumbar SCS in 12 individuals with SCI by a test-battery approach, before, immediately after and 2 h after intervention. Stimulation was applied for 30 min at 50 Hz with an intensity sub-threshold for eliciting reflexes in lower extremity muscles. The tests included evaluations of stretch-induced spasticity (Modified Ashworth Scale [MAS] sum score, pendulum test, electromyography-based evaluation of tonic stretch reflexes), clonus, cutaneous-input-evoked spasms, and the timed 10 m walk test. Across participants, the MAS sum score, clonus, and spasms were significantly reduced immediately after SCS, and all spasticity measures were improved 2 h post-intervention, with large effect sizes and including clinically meaningful improvements. The effect on walking speed varied across individuals. We further conducted a single-case multi-session study over 6 weeks to explore the applicability of transcutaneous SCS as a home-based therapy. Self-application of the intervention was successful; weekly evaluations suggested progressively improving therapeutic effects during the active period and carry-over effects for 7 days. Our results suggest that transcutaneous SCS can be a viable non-pharmacological option for managing spasticity, likely working through enhancing pre- and post-synaptic spinal inhibitory mechanisms, and may additionally serve to identify responders to treatments with epidural SCS.
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Affiliation(s)
- Ursula S Hofstoetter
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Brigitta Freundl
- Neurological Center, SMZ Baumgartner Hoehe, Otto-Wagner-Hospital, Vienna, Austria
| | - Simon M Danner
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Matthias J Krenn
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi.,Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, Mississippi
| | - Winfried Mayr
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Heinrich Binder
- Neurological Center, SMZ Baumgartner Hoehe, Otto-Wagner-Hospital, Vienna, Austria
| | - Karen Minassian
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
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Yen HC, Chen WS, Jeng JS, Luh JJ, Lee YY, Pan GS. Standard early rehabilitation and lower limb transcutaneous nerve or neuromuscular electrical stimulation in acute stroke patients: a randomized controlled pilot study. Clin Rehabil 2019; 33:1344-1354. [PMID: 30977392 DOI: 10.1177/0269215519841420] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We investigated adding lower limb transcutaneous nerve stimulation or neuromuscular electrical stimulation to standard early rehabilitation in acute stroke patients. DESIGN An assessor-blinded, randomized controlled pilot study. SETTING A medical stroke center. SUBJECTS First-stroke patients aged 20-80 years admitted to the stroke center within 24 hours post stroke. INTERVENTIONS A total of 42 participants were randomly assigned to groups: transcutaneous nerve stimulation + standard early rehabilitation, neuromuscular electrical stimulation + standard early rehabilitation, or standard early rehabilitation-only. Transcutaneous nerve or neuromuscular electrical stimulation was delivered to the affected tibialis anterior and quadriceps muscles for 30 minutes a day, five days per week for two weeks. MAIN MEASURES The Postural Assessment Scale for Stroke Patients, the Functional Independence Measure, and three mobility milestones, namely, sitting for >five minutes, standing for >one minute, and walking ⩾50 m, were evaluated, respectively, at baseline, at the two-week post-intervention, and at two-week follow-up. RESULTS Significant differences existed in the Postural Assessment Scale for Stroke Patients scores between the transcutaneous nerve stimulation and standard early rehabilitation-only groups measured at two-weeks post-intervention (mean (SD) = 31.38 (5.39) and 18.00 (8.65), respectively) and at the two-week follow-up (34.08 (2.69) and 26.14 (7.77), respectively). A higher proportion of participants could walk ⩾50 m independently in the transcutaneous nerve stimulation group than in the standard early rehabilitation-only group at the two-week post-intervention (P = 0.013) and two-week follow-up (P = 0.01) marks. CONCLUSION Two weeks of transcutaneous nerve stimulation added to standard early rehabilitation improved postural stability and walking in acute stroke patients.
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Affiliation(s)
- Hsiao-Ching Yen
- 1 Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei
| | - Wen-Shiang Chen
- 2 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei
| | - Jiann-Shing Jeng
- 3 Stroke Center & Department of Neurology, National Taiwan University Hospital, Taipei
| | - Jer-Junn Luh
- 4 School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei
| | - Ya-Yun Lee
- 4 School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei
| | - Guan-Shuo Pan
- 1 Division of Physical Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei
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Mahmood A, Veluswamy SK, Hombali A, Mullick A, N M, Solomon JM. Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2019; 100:751-768. [DOI: 10.1016/j.apmr.2018.10.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/15/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
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Alhusaini AA, Fallatah S, Melam GR, Buragadda S. Efficacy of transcutaneous electrical nerve stimulation combined with therapeutic exercise on hand function in children with hemiplegic cerebral palsy. Somatosens Mot Res 2019; 36:49-55. [PMID: 30913943 DOI: 10.1080/08990220.2019.1584555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Transcutaneous electrical nerve stimulation (TENS) is a nonpharmacological method used to reduce spasticity. It was also assumed that TENS reduces pain and therefore improves limb function. Most of the previous studies about the effect of TENS were done in the lower limb and in stroke patients. There is a lack of enough literature about the direct and indirect effects of TENS in the upper limb. Hence, our study aimed to determine whether TENS combined with therapeutic exercises helps to improves hand function by reducing spasticity in children with hemiplegic cerebral palsy (CP). MATERIALS AND METHODS Twenty-nine children with hemiplegic CP were randomly assigned to the TENS group (n = 15) or the control group (n = 14). The TENS group received traditional physical therapy with the adjunct application of conventional TENS for 30 minutes (pulse duration, 250 µs; pulse rate, 100 Hz) on the wrist extensors, once daily, 3 days a week, for 8 weeks, while the control group received traditional physical therapy. RESULTS The results showed a significant intergroup difference in handgrip strength over the 8-week period. The time to accomplish the Jebsen Taylor Hand Function Test (JTHFT) task decreased by 48% and the ABILHAND-Kids questionnaire scores improved by 23% in the TENS group. CONCLUSIONS The use of TENS in combination with therapeutic exercise may improve strength and hand function.
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Affiliation(s)
- Adel A Alhusaini
- a The Rehabilitation Health Sciences Department, College of Applied Medical Sciences , King Saud University , Riyadh , Saudi Arabia
| | - Saber Fallatah
- b Rehabilitation Department , Medical Rehabilitation Hospital , Riyadh , Saudi Arabia
| | - Ganeswara Rao Melam
- c Rehabilitation Health Sciences Department, College of Applied Medical Sciences , King Saud University , Riyadh , Saudi Arabia
| | - Syamala Buragadda
- c Rehabilitation Health Sciences Department, College of Applied Medical Sciences , King Saud University , Riyadh , Saudi Arabia
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Marcolino MAZ, Hauck M, Stein C, Schardong J, Pagnussat ADS, Plentz RDM. Effects of transcutaneous electrical nerve stimulation alone or as additional therapy on chronic post-stroke spasticity: systematic review and meta-analysis of randomized controlled trials. Disabil Rehabil 2018; 42:623-635. [PMID: 30326752 DOI: 10.1080/09638288.2018.1503736] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose: To evaluate the effects and to compare transcutaneous electrical nerve stimulation protocols, alone or as additional therapy in chronic post-stroke spasticity through a systematic review and meta-analysis of randomized clinical trials.Methods: Search was conducted in MEDLINE, Cochrane Library, EMBASE and Physiotherapy Evidence Database through November 2017 (CRD42015020146). Two independent reviewers performed articles selection, data extraction and methodological quality assessment using the Cochrane Collaboration's risk of bias tool. The main outcome was spasticity assessed with Modified Ashworth Scale or other valid scale. Meta-analysis was conducted using random effects method, and pooled-effect results are mean difference with 95% confidence interval.Results: Of 6506 articles identified, 10 studies with 360 subjects were included in the review. Transcutaneous electrical nerve stimulation alone or as additional therapy is superior to placebo TENS to reduce post-stroke spasticity assessed with Modified Ashworth Scale (-0.52 [-0.74 to -0.30] p < 0.0001, 6 studies), especially in lower limbs (-0.58 [-0.82 to -0.34] p < 0.0001, 5 studies), which is in accordance with the studies that used other scales. Low frequency TENS showed a slightly larger improvement than high-frequency, but without significant difference between subgroups. Most studies present low or unclear risk of bias.Conclusion: Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post-stroke spasticity, mainly as additional therapy to physical interventions. Studies with better methodological quality and larger sample are needed to increase evidence power.Implications for RehabilitationTranscutaneous electrical nerve stimulation as additional treatment to physical interventions can lead to additional reduction in chronic post-stroke spasticity.High and low frequency transcutaneous electrical nerve stimulation showed similar results, with a smaller numerical superiority of low frequency TENS.More studies are needed to substantiate the best protocol of transcutaneous electrical nerve stimulation to the treatment of spasticity.
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Affiliation(s)
- Miriam Allein Zago Marcolino
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Melina Hauck
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Cinara Stein
- Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Jociane Schardong
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Aline de Souza Pagnussat
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil.,Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Rodrigo Della Méa Plentz
- Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil.,Graduate Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
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James ND, McMahon SB, Field-Fote EC, Bradbury EJ. Neuromodulation in the restoration of function after spinal cord injury. Lancet Neurol 2018; 17:905-917. [PMID: 30264729 DOI: 10.1016/s1474-4422(18)30287-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 12/13/2022]
Abstract
Neuromodulation, the use of electrical interfaces to alter neuronal activity, has been successful as a treatment approach in several neurological disorders, including deep brain stimulation for Parkinson's disease and epidural spinal stimulation for chronic pain. Neuromodulation can also be beneficial for spinal cord injury, from assisting basic functions such as respiratory pacing and bladder control, through to restoring volitional movements and skilled hand function. Approaches range from electrical stimulation of peripheral muscles, either directly or via brain-controlled bypass devices, to stimulation of the spinal cord and brain. Limitations to widespread clinical application include durability of neuromodulation devices, affordability and accessibility of some approaches, and poor understanding of the underlying mechanisms. Efforts to overcome these challenges through advances in technology, together with pragmatic knowledge gained from clinical trials and basic research, could lead to personalised neuromodulatory interventions to meet the specific needs of individuals with spinal cord injury.
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Affiliation(s)
- Nicholas D James
- Regeneration Group, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, Guy's Campus, King's College London, London, UK; Center for Neuroprosthetics and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology, Lausanne, Switzerland
| | - Stephen B McMahon
- Regeneration Group, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, Guy's Campus, King's College London, London, UK
| | - Edelle C Field-Fote
- Shepherd Center, Crawford Research Institute, Atlanta, GA, USA; Division of Physical Therapy, Emory University School of Medicine, Atlanta, GA, USA; Georgia Institute of Technology, School of Biological Sciences, Program in Applied Physiology, Atlanta, GA, USA
| | - Elizabeth J Bradbury
- Regeneration Group, Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, Guy's Campus, King's College London, London, UK.
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Managing Spasticity in a Pregnant Woman with Spinal Cord Injury: a Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0198-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Sivaramakrishnan A, Solomon JM, Manikandan N. Comparison of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) for spasticity in spinal cord injury - A pilot randomized cross-over trial. J Spinal Cord Med 2018; 41:397-406. [PMID: 29067867 PMCID: PMC6055976 DOI: 10.1080/10790268.2017.1390930] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Spasticity following spinal cord injury (SCI) can impair function and affect quality of life. This study compared the effects of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) on lower limb spasticity in patients with SCI. DESIGN Double blind randomized crossover design. SETTING Neuro-rehabilitation unit, Manipal University, India. PARTICIPANTS Ten participants (age: 39 ± 13.6 years, C1-T11, 1-26 months post SCI) with lower limb spasticity were enrolled in this study. INTERVENTIONS Participants were administered electrical stimulation with TENS and FES (duration - 30 minutes) in a cross over manner separated by 24 hours. OUTCOME MEASURES Spasticity was measured using modified Ashworth scale (MAS) [for hip abductors, knee extensors and ankle plantar flexors] and spinal cord assessment tool for spastic reflexes (SCATS). Assessments were performed at baseline, immediately, 1 hour, 4 hours, and 24 hours post intervention. RESULTS A between group analysis did not show statistically significant differences between FES and TENS (P > 0.05). In the within group analyses, TENS and FES significantly reduced spasticity up to 4 hours in hip adductors and knee extensors (P < 0.01). SCATS values showed significant reductions at 1 hour (P = 0.01) following TENS and 4 hours following FES (P = 0.01). CONCLUSION A single session of electrical stimulation with FES and TENS appears to have similar anti-spasticity effects that last for 4 hours. The findings of this preliminary study suggest that both TENS and FES have the potential to be used as therapeutic adjuncts to relieve spasticity in the clinic. In addition, FES may have better effects on patients presenting with spastic reflexes.
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Affiliation(s)
- Anjali Sivaramakrishnan
- Correspondence to: Anjali Sivaramakrishnan, Graduate Program in Rehabilitation Science, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, USA. . Phone: 773-575-1007
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Rapidi CA, Tederko P, Moslavac S, Popa D, Branco CA, Kiekens C, Varela Donoso E, Christodoulou N. Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med 2018; 54:797-807. [PMID: 29952157 DOI: 10.23736/s1973-9087.18.05374-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions. EVIDENCE ACQUISITION A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. EVIDENCE SYNTHESIS The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure. CONCLUSIONS The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.
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Affiliation(s)
| | - Piotr Tederko
- Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
| | - Sasa Moslavac
- Department of Physical and Rehabilitation Medicine, Special Hospital for Medical Rehabilitation, Varaždinske Toplice, Croatia
| | - Daiana Popa
- Clinical Rehabilitation Hospital Felix-Spa Bihor County, Oradea, Romania
| | - Catarina A Branco
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar de Entre o Douro e Vouga E.P.E, Porto, Portugal
| | - Carlotte Kiekens
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Enrique Varela Donoso
- Physical and Rehabilitation Medicine Department, Complutense University School of Medicine, Madrid, Spain
| | - Nicolas Christodoulou
- Medical School, European University Cyprus, Nicosia, Cyprus.,UEMS PRM Section, Brussels, Belgium
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Springer S, Kozol Z, Reznic Z. Ulnar Nerve Conduction Block Using Surface Kilohertz Frequency Alternating Current: A Feasibility Study. Artif Organs 2018. [PMID: 29517147 DOI: 10.1111/aor.13119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The aim of this study was to test the effects of kilohertz frequency alternating current (KHFAC) surface stimulation applied to the ulnar nerve on force and myoelectrical activity of the abductor digiti minimi (ADM) muscle. Eighteen healthy volunteers (age: 27.6 ± 7.9 years; 10 males, 8 females) were included in the study. Each subject participated in one session during which a biphasic 7 kHz rectangular pulse was delivered above the medial epicondyle of the humerus to induce ulnar nerve blocking. ADM electromyographic (EMG) activity and contraction force were measured before (Pre), immediately after, and following 5 and 10 min post stimulation (post 1, post 2). The results showed that EMG activity decreased immediately after stimulation compared to prestimulation, it returned to the level of prestimulation at 5 min (post 1), and decreased again at 10 min (post 2). Furthermore, analysis of compound adjusted z-score indicated significant decrease of force and myoelectrical activity immediately, and 10 min post stimulation. The findings, which demonstrate that KHFAC surface stimulation of the ulnar nerve may decrease the motor activity of intrinsic hand muscle, can help to develop future methods of neuromodulation to treat hand spasticity.
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Affiliation(s)
- Shmuel Springer
- Department of Physiotherapy, Ariel University, Ariel, Israel
| | - Zvi Kozol
- Department of Physiotherapy, Ariel University, Ariel, Israel
| | - Zvi Reznic
- Spotlight Technologies, Tel Aviv, Israel
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Schröder J, Truijen S, Van Criekinge T, Saeys W. Peripheral somatosensory stimulation and postural recovery after stroke - a systematic review. Top Stroke Rehabil 2018; 25:312-320. [PMID: 29473456 DOI: 10.1080/10749357.2018.1440694] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Purpose It is hypothesized that peripheral somatosensory stimulation (PSS) can promote postural recovery after stroke by increasing afferent input and postural contribution of the paretic leg. Therefore, this systematic review aims to investigate which PSS approaches are documented and investigated on effectiveness. Methods Five databases (PubMed, Web of Science, PEDro, Cochrane Library Trials, RehabData) have been searched on clinical studies in stroke rehabilitation, investigating PSS, which is defined as a non-motor and focal stimulation to the paretic leg aiming an increase in somatosensory input. Results Twenty studies present different PSS approaches (mainly electrical and vibration stimulation) and following results: (I) There is an immediate effect after a single session of PSS on postural stability. In contrast, (II) repetitive sessions of isolated PSS led to highly inconsistent results. Finally, (III) PSS as an adjuvant to exercises did promote long-term postural recovery. Conclusion PSS is found to be effective immediately and on a long-term as an adjuvant therapy only in improving postural stability in a chronic stroke population. However, if PSS enhances paretic leg postural contribution remains unclear. Future research is warranted considering promising results and high prevalence of postural instability impacting daily life of stroke survivors.
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Affiliation(s)
- Jonas Schröder
- a Department of Rehabilitation Sciences and Physiotherapy , University of Antwerp , Antwerp , Belgium
| | - Steven Truijen
- a Department of Rehabilitation Sciences and Physiotherapy , University of Antwerp , Antwerp , Belgium
| | - Tamaya Van Criekinge
- a Department of Rehabilitation Sciences and Physiotherapy , University of Antwerp , Antwerp , Belgium
| | - Wim Saeys
- a Department of Rehabilitation Sciences and Physiotherapy , University of Antwerp , Antwerp , Belgium
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Kwong PW, Ng GY, Chung RC, Ng SS. Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysis. Clin Rehabil 2017; 32:1203-1219. [PMID: 29232981 DOI: 10.1177/0269215517745349] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate (1) the effectiveness of transcutaneous electrical nerve stimulation (TENS) at improving lower extremity motor recovery in stroke survivors and (2) the optimal stimulation parameters for TENS. REVIEW METHODS A systematic search was conducted for studies published up to October 2017 using eight electronic databases (CINAHL, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PEDro, PubMed and Web of Science). Randomized controlled trials that evaluated the effectiveness of the application of TENS at improving lower extremity motor recovery in stroke survivors were assessed for inclusion. Outcomes of interest included plantar flexor spasticity, muscle strength, walking capacity and balance. RESULTS In all, 11 studies met the inclusion criteria which involved 439 stroke survivors. The meta-analysis showed that TENS improved walking capacity, as measured by either gait speed or the Timed Up and Go Test (Hedges' g = 0.392; 95% confidence interval (CI) = 0.178 to 0.606) compared to the placebo or no-treatment control groups. TENS also reduced paretic plantar flexor spasticity, as measured using the Modified Ashworth Scale and Composite Spasticity Scale (Hedges' g = -0.884; 95% CI = -1.140 to -0.625). The effect of TENS on walking capacity in studies involving 60 minutes per sessions was significant (Hedges' g = 0.468; 95% CI = 0.201-0.734) but not in study with shorter sessions (20 or 30 minutes) (Hedges' g = 0.254; 95% CI = -0.106-0.614). CONCLUSION The results support the use of repeated applications of TENS as an adjunct therapy for improving walking capacity and reducing spasticity in stroke survivors.
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Affiliation(s)
- Patrick Wh Kwong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Gabriel Yf Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Raymond Ck Chung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Shamay Sm Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
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Khan F, Amatya B, Bensmail D, Yelnik A. Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews. Ann Phys Rehabil Med 2017; 62:265-273. [PMID: 29042299 DOI: 10.1016/j.rehab.2017.10.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Spasticity causes significant long-term disability-burden, requiring comprehensive management. This review evaluates evidence from published systematic reviews of clinical trials for effectiveness of non-pharmacological interventions for improved spasticity outcomes. METHODS Data sources: a literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, CINAHL, PubMed, and the Cochrane Library) databases for published systematic reviews up to 15th June 2017. DATA EXTRACTION AND SYNTHESIS two reviewers applied inclusion criteria to select potential systematic reviews, independently extracted data for methodological quality using Assessment of Multiple Systematic Reviews (AMSTAR). Quality of evidence was critically appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE). RESULTS Overall 18 systematic reviews were evaluated for evidence for a range of non-pharmacological interventions currently used in managing spasticity in various neurological conditions. There is "moderate" evidence for electro-neuromuscular stimulation and acupuncture as an adjunct therapy to conventional routine care (pharmacological and rehabilitation) in persons following stroke. "Low" quality evidence for rehabilitation programs targeting spasticity (such as induced movement therapy, stretching, dynamic elbow-splinting, occupational therapy) in stroke and other neurological conditions; extracorporeal shock-wave therapy in brain injury; transcranial direct current stimulation in stroke; transcranial magnetic stimulation and transcutaneous electrical nerve stimulation for other neurological conditions; physical activity programs and repetitive magnetic stimulation in persons with MS, vibration therapy for SCI and stretching for other neurological condition. For other interventions, evidence was inconclusive. CONCLUSIONS Despite the available range of non-pharmacological interventions for spasticity, there is lack of high-quality evidence for many modalities. Further research is needed to judge the effect with appropriate study designs, timing and intensity of modalities, and associate costs of these interventions.
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Affiliation(s)
- Fary Khan
- Department of rehabilitation medicine, Royal Melbourne Hospital, 34-54, Poplar Road, Parkville, VIC 3052, Victoria, Australia; Department of medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Bhasker Amatya
- Department of rehabilitation medicine, Royal Melbourne Hospital, 34-54, Poplar Road, Parkville, VIC 3052, Victoria, Australia; Department of medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Djamel Bensmail
- UMR1179, Inserm, department of physical and rehabilitation medicine, Spinal Cord Injury Unit, Raymond-Poincaré Hospital, AP-HP, University of Versailles-Saint-Quentin-en-Yvelines, Graces, France
| | - Alain Yelnik
- PRM Department, St-Louis-Lariboisière, F. Widal University Hospital, Paris, France
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Sternowski K, Perone K. Uses of Electrical Stimulation for the Rehabilitation of People with Multiple Sclerosis: A Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0157-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: A randomized controlled study. Gait Posture 2017; 54:183-187. [PMID: 28324754 DOI: 10.1016/j.gaitpost.2017.03.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 02/28/2017] [Accepted: 03/04/2017] [Indexed: 02/02/2023]
Abstract
Sit-to-stand is a fundamental movement of human being for performing mobility and independent activity. However, Stroke people symptoms experience difficulty in conducting the sit-to-stand due to paralysis and especially ankle spasticity. Recently, transcutaneouselectrical- stimulation (TENS) is used to reduce pain but also to manage spasticity. The purpose of this study was to determine (1) whether TENS would lead to ankle spasticity reduction and (2) whether sit-to-stand training combined with TENS would improve spasticity, muscle strength and balance ability in stroke patients. Forty-stroke patients were recruited and were randomly divided into two groups: TENS group (n=20) and sham group (n=20). All participants underwent 30-sessions of sit-to-stand training (for 15-min, five-times per week for 6-weeks). Prior to each training session, 30-min of TENS over the peroneal nerve was given in TENS group, whereas sham group received non-electrically stimulated TENS for the same amount of time. Composite-Spasticity-Score was used to assess spasticity level of ankle plantar-flexors. Isometric strength in the extensor of hip, knee and ankle were measured by handheld dynamometer. Postural-sway distance was measured using a force platform. The spasticity score in the TENS group (2.6±0.8) improved significantly greater than the sham group (0.7±0.8, p<0.05). The muscle strength of hip extensor in the TENS group (2.7±1.1kg) was significantly higher than the sham group (1.0±0.8kg, p<0.05). Significant improvement in postural-sway was observed in the TENS group compared to the sham group (p<0.05). Thus, sit-to-stand training combined with TENS may be used to improve the spasticity, balance function and muscle strength in stroke patients.
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Naro A, Leo A, Russo M, Casella C, Buda A, Crespantini A, Porcari B, Carioti L, Billeri L, Bramanti A, Bramanti P, Calabrò RS. Breakthroughs in the spasticity management: Are non-pharmacological treatments the future? J Clin Neurosci 2017; 39:16-27. [DOI: 10.1016/j.jocn.2017.02.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/12/2017] [Indexed: 12/16/2022]
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